What your nursing textbook didn't teach

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. 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 anyways), a 1-2 patient assignment, get the occasional med pass, but you're still in practice or 'safe' mode.

Once you start your first job, you realize that the game changes from practice mode 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, it changes your outlook on everything and you'll see yourself develop from your work experiences whether they be good or bad.

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, sometimes 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 and when 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 rarely 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. Life is short.

As a new grad in the ICU, I’ve only experienced a patient death a couple of times as a nurse assistant. Nurses are expected to assist in the caring of the lives of the young, old and also for the deaths of the young and old. However, dealing with losses can be especially hard when Mr. Smith has been on the unit for 6 months and passed away while you have to go next door, put on a smile and take care of Mr. Jones as if you didn’t lose a patient. You quickly learn the value of a life, but sometimes dealing with death doesn’t come so quickly. Debriefing is important and you must recognize and allow yourself to grieve.

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