Congratulations! You got your first job as a nurse! Now you’re ready to put your countless hours of clinical, simulation, labs and classes to work! While nursing school is your foundation and your backbone, there are just some things that nursing school cannot possibly prepare you for adequately. In school, you learn expected outcomes — how things are supposed to happen. For most, you get an 8hr, not 12hr day for clinical (not that I’d really want a 12 hour clinical day), a 1-2 patient assignment, get the occasional med pass, but you’re still in a practice or ‘safe’ mode.

Once you start your first job, you realize that the game changes from practice to advanced mode pretty quickly, and you have to learn how to deal with unexpected outcomes more often than expected ones.

Nursing school didn’t teach you:

1.  How to be a nurse.

I’ve mentioned before that nursing isn’t just a career but that it becomes part of your personality.  You graduate nursing school, take the NCLEX, receive your license,  but nursing is much more than the cookie-cutter description of caring angels that heal, or the stereotypical image of bedpans, pills and shots. There’s no set script of how to be a nurse and every nurse has their strengths and weaknesses.  Nursing changes you, and I’m too new to truly explain this, but it changes your outlook on everything and you’ll see yourself develop into someone different.

2. How to give a good great report.

We all are familiar with SBAR, but to be honest, it works best in the lab, on your sim man whose oxygen level is declining and you have to call your provider to get an order for albuterol.   Getting report is another challenge, as you have no idea what you should or shouldn’t write down.  I find that the most challenging thing about report is communicating effectively and using the proper terminology.  “Yeah he’s been breathing fine, but his lungs sound a bit junky” isn’t the best way to communicate that your patient requires high-flow nasal cannula to maintain his oxygen saturation and has sonorous rhonchi in his left upper lobe.  I’m gradually learning how to not use so many euphemisms, but actually tell the oncoming nurse what exactly is going on.   The most important thing about report is to inform the next shift of the things that they can’t get from the electronic medical record.  If you forgot to tell them that your patient has a past medical history of UTI’s, it’s OK, it’s in the chart.  However, if you forget to tell them that your patient is deaf, needs dentures, and has a wife that prefers to bathe them every morning, the next shift may have a harder time trying to find that info and communicating with their patient.

3. How to deal with patient’s family.

I think my school did a great job through our simulations by having a “family member ” present that we had to deal with.  However, in critical care, family will be there 24/7.  24/7.  While I don’t mind it,  you not only have to learn how to deal with overprotective, in-your-face families, but vise versa.  There will be patients whose family isn’t involved until the talk of DNR and withdrawing care comes up.  You have to learn how to explain all of the lines, drains and tubes coming out of your patient, and what they mean.  You also have to learn when to tell the patient of their lab results and when to not discuss their care because they don’t want their great-aunt Flo to know that they’re a smoker.  Part of taking care of the patient truly involves the patient’s family also.  It’s best to not ignore their presence; they’re trusting you with their loved ones life and they just want their concerns to be addressed to lessen their worries.

4. How to multitask, delegate and prioritize.

Regardless of how many clinical hours and simulation I’ve had, it would never fully prepare me to learn how to multitask, delegate and prioritize my care.  Like I mentioned earlier, everything is in practice mode, and you don’t necessarily get to practice that same scenario in lab again unless you completely screwed it up.  We can debrief, and talk about how you can do it better next time, but until you actually do it, and have it become a habit, you’re going to be all over the place.  It’s always helpful to try to plan your day, but things will never EVER go as planned! Prioritization is definitely something that you learn to do over time… you won’t wake up doing things in an efficient nursing manner just because your badge says RN (if only it was that easy…)

5. The truth about nurses eating their young.

I’ve heard this time and time again, but it’s becoming a myth for me.  In the critical care setting where I am, everyone is extremely supportive and will answer any question you have.  Everyone is always busy, so experienced nurses really don’t have time to eat their young.  However, in the land of nursing school, I’ve seen some instances where it’s happened, but once you have RN after your name, things change a bit.  It’s common for new nurses to feel somewhat alienated, but that’s an expectation when you’re new on a unit.  Don’t worry about making friends and going out for breakfast after your night shifts — become a great nurse first and the socialization and friends will come later.

For my new and experienced nurses: What are some things you feel that nursing school didn’t teach you???