The Everything New Nurse Book, 2nd Edition: Gain confidence, manage your schedule, and be ready for anything!

Introduction

WELCOME TO THE WORLD of nursing. As you embark on your new career, know that you have made a wise and wonderful choice to give of yourself to help make a difference in someone’s life every day. Nursing is one of the most rewarding and yet challenging careers. It can be a thankless job and at the same time, nursing can bring you countless hours of joy and some of the most heartfelt love.

Nursing is one of the most physically and emotionally demanding careers. You will require a great deal of physical stamina and a strong sense of humor to perform your daily duties. Nurses combine the art of caring with a broad scientific knowledge base to provide care, promote wellness, and improve the lives of their patients. It takes strong communication skills, both written and oral, combined with a scientific mind and a warm heart and soul to form the foundation for a good nurse.

You will learn to laugh and to cry with your patients, to share their joys and disappointments and sorrows. They will all touch your life in very different ways and some will become a part of you forever. Nursing is a lifelong learning experience. As you approach your new career, you will discover just how much you didn’t learn in school. This may frighten you and cause you to feel incompetent, give you much self-doubt, and even make you want to quit. Be patient, give yourself time (at least a year) to grow into your new role. You will learn something new every day. You will teach your patients how to improve their lives, to become responsible for their own outcomes, and to be independent in their own health care.

You will learn many new techniques and skills and nurture many talents and abilities, some of which you never knew you had. You will become competent and lose your fear and feelings of inadequacy as you grow into your new profession. You will also experience many negative aspects and encounter nurses who are burning out. Your enthusiasm could help them to rediscover why they chose nursing and how to make nursing important again in their own lives.

This book is based on the experiences of many nurses and is meant to help you to understand that you are not alone in your feelings at any stage of your career. Every nurse was once a new grad. Every nurse has had just as many firsts as you will: first shot, first birth, first death, first error, first patient, first special moment when it all makes sense. Share in their triumphs and failures as you grow into one of the finest professions.

Always smile and be honest. Consider how you would like to be treated if you were in this predicament, and never take care of someone in a manner less than what you would demand for your loved ones. Set the bar high and demand excellence; mediocrity is common, boring, and unacceptable. Be professional.

Always remember to recharge your own batteries. Take care of yourself so that you have the strength, stamina, and desire to care for others who need you. Learn from your mistakes and move on. Enjoy your career and always keep track of your accomplishments and successes. Find something positive about every day. If you ever lose track of why you became a nurse, think back to those moments and your doubts will fade. Good luck and thank you for becoming a nurse.

CHAPTER 1

What Is a Nurse?

A nurse is someone who cares for the sick and infirm. But a nurse is so much more. The nurse comforts the sick and dying and participates in the joy of birth. A nurse is your best friend when you lie awake in a hospital bed at night scared and lonely. A nurse may also seem like your worst enemy when he comes at you with needles and tubes to probe your body.

Definitions of Nursing

A nurse is a professional caregiver. Someone who advocates for patients’ rights, promotes health, educates patients and families, and strives to eliminate pain and suffering. A nurse carries a large responsibility in the care and treatment of her patients. Nursing is one of the most rewarding professions and yet at times can be one of the most frustrating and thankless. A nurse is a highly skilled individual who learns to combine the scientific aspect of health care with the fine art of caring.

The following definitions will provide you with an understanding of the basic levels of the nursing profession. They will serve as building blocks for determining what education is required, what roles are open to each level, and how to explore opportunities for advancement.

Nurse: someone who cares for the sick and infirm. A nurse is a member of the health care team and provides different kinds of health care to patients based on the nurse’s level of education.

Registered Nurse (RN): a nurse who has graduated with a diploma or a degree (Associate Degree in Nursing [ADN] to PhD) from a state-approved nursing program, passed the state board examination for professional nurses, and has been granted a license by the state to practice professional nursing in that state. RNs with advanced degrees and certificates will have increased options for their scope of practice.

Licensed Practical (or Vocational) Nurse (LPN/LVN): a technical nurse who has graduated from a state-approved practical or vocational nursing program, passed the state board examination for practical nursing, and has been granted a license to practice in that state as a practical nurse. The LPN/LVN works under the supervision of an RN or a physician to provide patient care. With IV Certification, the LPN/LVN can perform certain aspects of IV care. The title of practical or vocational nurse varies by state law, but the role is essentially the same. Most states use the practical nurse title; California and Texas use vocational nurse.

Certified Nursing Assistant (CNA): also known as a nurse’s aide, is unlicensed. A CNA delivers limited care to patients under the supervision of licensed nurses. The CNA may take vital signs and assist in activities of daily living such as giving baths, making beds, dressing, feeding, and positioning patients. The CNA completes a training course that includes classroom and clinical instruction. They are regulated by state agencies.

Scope of Practice: each licensed or certified member of the health care team is allowed to perform certain duties based on the content and level of education received, the license or certificate granted, and the specifics of the laws and regulations of the state in which they are practicing.

Nurse Practice Act (NPA): the group of laws in a state that protect the public health. It defines the scope of practice for nurses in that state. The Nurse Practice Act also includes the requirements for education and licensing, as well as disciplinary and punitive measures for unsafe practice. It is the responsibility of every nurse to know the responsibilities and limitations outlined in the NPA of the state(s) in which the nurse practices.

State Board of Nursing: the governing board in each state that oversees the statutory laws that comprise the NPA for that state. This board is responsible for protecting the public by determining who is competent to practice nursing in that state and suspending or revoking the license of anyone who is deemed incompetent.

For additional information and definitions, please refer to Appendix A. There are many other members of the health care team. In some settings, medical assistants, CNAs, and other non-licensed personnel may be referred to as the nurse. While they play an important role in health care delivery, confusing their role with that of the nurse is a practice that is misleading and at the very least should be discouraged.

Roles for Nurses

There are several roles for nurses. One role is the practical nurse, sometimes referred to as the technical nurse. This is the LPN/LVN. The other is the professional nurse. This is the RN. Both play an essential part as members of the health care team. Their roles and responsibilities vary. An RN can perform any of the duties of an LPN, but the reverse is not true.

In some instances, an LPN/LVN’s skills at specific tasks may be more refined than those of her supervising RN. This can often be the case because the LVN has the primary responsibility for performing bedside nursing and tasks, while the RN is given a supervisory responsibility for the patient’s care and often forgoes the hands-on practice of direct patient care.

RN training involves more science, math, patient assessment, critical thinking, and theoretical aspects. This includes the nursing process, which encompasses the whole patient and his response to his illness as well as patient treatment.

Both the LPN and RN combine the knowledge they acquired in school with their own art of compassion and caring to provide excellent care. Beyond the basics of science and the treatment of disease that both LPNs and RNs receive, LPN training is primarily focused on bedside nursing and performing tasks such as changing dressings and Foley catheter care.

LPN/LVN Training

The technical nurse attends a vocational school. Some community colleges and adult education schools provide LPN training. This is usually a one-year to fifteen-month program that includes classroom as well as clinical hands-on instruction. After graduation, the nurse must sit for a board exam to become licensed to practice.

Professional organizations have been battling for years to make a distinction between nurses who have been educated at minimally the baccalaureate level as being professional nurses and those with a diploma or ADN nursing education being technical nurses. Those without a BSN would be given a grace period to acquire the degree or an option to work at a newly designated level. There was also a movement to eliminate the LPN role altogether.

Studies have repeatedly shown that patient mortality rates and quality of care are directly related to the level of education of the nursing staff, and the American Association of Critical-Care Nurses (AACN) believes that quality care hinges on having a highly educated workforce.

The wax and wane of the shortage of nurses has prevented further implementation of these distinctions. But when employers have an opportunity to pick and choose among qualified candidates, the hiring trend moves toward the higher-educated nurses.

RN Training

The RN has several options for education. Each level of education prepares the student for the role of a professional nurse. All nurses will sit for the same RN board exam in order to become licensed as a registered nurse. However, there are distinct differences in the programs and the level of preparation they provide. Consequently, salaries and opportunities for advancement are often tied to the level of education.

Diploma Nurse Program

The Diploma Nurse program was once a primary option for RNs, but it is rapidly disappearing. This is because nurses no longer work primarily in a hospital setting. There are only about twenty-five such programs left in the United States today. These programs provide nurses with a three-year, non-degreed nursing education. Diploma programs are usually associated with a teaching hospital and nurses reside in a dormitory setting. They attend classes in the hospital and work regular shifts on the floors of the hospital to obtain their hands-on clinical training. Today many diploma programs have combined with ADN programs at community colleges or offer practical or vocational nursing.

Associate’s Degree

Community colleges provide an Associate Degree in Nursing (ADN) program option for RNs. This is typically a two-year associate’s degree program. It includes the same general education/liberal arts courses required for any associate’s degree. For nurses, the curriculum will include math (minimum: algebra) and science (chemistry, physics, anatomy, and physiology and microbiology). The nursing courses include classroom instruction and hands-on clinical courses that may be provided at institutions available within the community.

Bachelor’s Degree

The third option is a four-year program, a Bachelor of Science in Nursing (BSN) in which the nurse completes all the general requirements for a bachelor’s degree with all the above math and science, as well as a comprehensive program in nursing. The nursing courses cover the same materials as the other programs but add a more intense study of the nursing process, nursing theory and models, and leadership skills. It is also a springboard for advanced degrees. As such, a BSN is often required for leadership roles and management positions in the nursing profession. In some cases, the RN must make a commitment to obtain a master’s degree in nursing within a timeframe. This is becoming more common again because of the shortage of nurses and the need to allow those with less education to advance more rapidly.

Advanced Degrees

Advanced degrees for nurses include fields such as a master’s or PhD in nursing, health care, and health care administration. A Master in Business Administration (MBA) in health care or health care administration is also a popular choice for nurses with an inclination for business and managing health care organizations such as home health agencies, clinics, and hospitals. Advance practice nurses, such as NPs, nurse midwives, nurse anesthetists, and clinical nurse specialists, minimally require an MSN.

Opportunities for Nurses

Health care as a whole is one of the fastest growing career opportunities worldwide. Combined with the growing shortage of personnel, nurses are in high demand and will remain so for at least another ten to twenty years. Part of the reason for the shortage is the ever-expanding opportunity and accompanying need for nurses. Nurses no longer work primarily in hospitals, nursing homes, doctor’s offices, and clinics. These will continue to be major employers for nurses, but as new opportunities arise because of constant changes in the workplace, nurses are leaving these sites.

New nurses are also exploring the opportunities that have grown out of advances in technology and medicine. Community-based nursing is on the rise as the trend for treating patients in their homes in lieu of hospitalization increases. Home health and hospice fields will continue to grow faster than many other nursing fields over the next decade.

Expanding nursing roles for RNs are in areas such as information technology, forensics, telemedicine, prisons, geriatric day care, assisted living facilities, schools, research, home health, private duty, hospice, holistic care, and the military. Many corporations are now hiring an on-site nurse to assist with employee health issues.

Health Care Reform and the Nursing Profession

The Patient Protection and Affordable Care Act, also known as Health Care Reform of 2010, will help to advance the nursing profession in multiple ways. When President Obama was campaigning for office in 2008, the American Nurses Association (ANA) chose to endorse him because he took the time to listen and learn about the issues facing nurses today and promised to work to improve as many as he can.

By expanding access to health care coverage for millions more Americans, one of the biggest impacts of this act has been, and will continue to be, using nurses to provide more care and patient education to help reduce the high costs of health care, as well as expand the availability.

Nurse practitioners have long been used to help provide primary care in areas such as women’s health, pediatrics, and family medicine, especially under HMO (i.e., managed care) insurance plans, and in low-cost community- and retail-based clinics. Many more NPs are going to be needed in the future to meet the need of the public for health care. As nurses leave other roles to become NPs, replacement nurses will be needed to fill their vacancies.

With a focus shift to preventive care and wellness, all nurses will take on more responsibility for educating patients to assist them in taking more responsibility for their own health care and outcomes.

The Affordable Care Act also designates funding increases to provide for educational assistance for nurses at all levels from LPN to PhD RN. A major focus of the funding will be on educating nurse educators so that more nurses can be educated rather than turned away because of the lack of nurse educators.

Funds will also be directed to the Nursing Workforce Diversity Program to improve cultural diversity among nurses. In addition, funds will be added to the Nurse Education, Practice and Retention grant program to update the quality component, help nurses obtain a stronger background in quality improvement, and help implement mandated quality improvement across the health care delivery process.

LPN/LVNs

Most of these new opportunities for nurses require an RN and often a BSN, but some areas do offer opportunities for LPNs as well. Sometimes these are limited roles, such as in home health care, hospice, and private duty, where the LPN can perform certain tasks such as Foley care, venipuncture for lab specimens, wound care, ventilator care, and basic bedside nursing.

One expanded role for LPNs is IV care. IV Certification at present is an additional optional course of study in most states. Each state’s Nurse Practice Act for LPNs spells out the level of IV care that this certification covers. In most instances, dressing changes, hanging new bags, and possibly adjusting the rate of flow is about all that is allowed. New laws are being legislated in some states to allow LPNs to flush central lines and perform central-line care. Inserting IV lines is not likely to become standard practice for LPNs in most states.

Be sure that you have a clear understanding of the policies of your employer as well as the Nurse Practice Act in the state in which you practice. Never rely on the culture of what is acceptable in your facility as the final rule. You are responsible for knowing the law and abiding by it. If some administrator or a physician has bent the law for the convenience of the facility, you can be held liable.

Advance Practice Nurses

Advance practice nurses (APNs) hold advanced degrees and/or certifications in specialties that include certified registered nurse anesthetists (CRNA), certified nurse-midwives (CNM), certified diabetic educators (CDE), clinical nurse specialists (CNS), and nurse practitioners (NP) in such areas as palliative care, pediatrics, geriatrics, family practice, women’s health, and mental health. There are many more areas of specialization and more to come in the future. Nurse practitioners work under the supervision of a physician. In most states, they can prescribe medications and non-complex treatments. They assess patients and can perform many procedures that are normally performed only by physicians, such as pap smears.

Pending legislation at the state and national levels may pave the way for even more changes in the range of opportunities for advance practice nurses. When Medicare and/or Medicaid reimbursement to nurse practitioners becomes possible everywhere in the United States, the Advanced Practice Registered Nurse (APRN) role will expand further, especially in rural areas where access to physician care is limited. NPs will serve to supplement the care. In particular, case management of patients with palliative care and mental health issues could once again be reimbursed when this legislation is passed and implemented.

Additional Opportunities

Nurses can be childbirth educators and lactation consultants, flight nurses, and legal nurse consultants. They can specialize in managed care, infection control, IV infusion, nutrition support, diabetes education, oncology, cardiology, and heart catheterization, and in case management of catastrophic illness and workers’ compensation cases.

In some instances, nurses holding a BSN can now become instructors in vocational and ADN programs. Generally, nurse educators must hold a master’s or PhD in nursing or education. In fact, even in vocational and ADN programs, the minimum requirement has been for a master’s prepared nurse educator. However, with the shortage of nurses and the need to increase enrollment in nursing programs, the BSN-prepared nurse now has more opportunities to teach.

Responsibilities of Nurses

All nurses provide direct patient care as directed by a physician. Both LVNs and RNs can take orders directly from physicians. In some states, however, the LVN must have the RN cosign any verbal orders the LVN takes. The LVNs can carry out the orders and report to the RN any significant findings or response to treatment. The RN would then assess the patient and report to the doctor. All verbal orders must be read back and verified.

All nurses promise to do no harm to any patient and are expected to uphold fundamental responsibilities to help to prevent illness and restore health, to help to alleviate pain and suffering, and to promote health. Nurses should also follow a code of ethics for nurses as set and frequently revised by the ANA. The International Council of Nurses (ICN) has also written a code of ethics for nurses that expands on the ANA’s code.

For the exact content of the codes of ethics, please refer to the organization’s website. The ANA website is www.nursingworld.org, then search for Code of Ethics. The ICN website is www.icn.ch/about-icn/code-of-ethics-for-nurses.

Highlights of the responsibilities and guidelines for the ethical and legal practice of nurses as outlined in these codes are:

The nurse is expected to provide care for a patient with respect for his human dignity and uniqueness as an individual regardless of race, creed, gender, socio-economic status, or the nature of the illness.

The nurse is responsible for safeguarding the patient’s right to privacy by honoring the confidentiality of information related to the patient.

The nurse is responsible for protecting her patient and the public from health and safety issues affected by illegal, incompetent, and unethical practices.

The nurse is responsible and accountable for her own nursing actions and judgments, as well as for those she is supervising.

The nurse is responsible for maintaining her own nursing competency.

The nurse is responsible for making informed decisions about her own skills and abilities, as well as for those to whom she might delegate responsibility. The nurse is expected to seek consultation if necessary before accepting or delegating the responsibility for any aspect of a patient’s care.

The nurse is expected to participate in the nursing profession’s ongoing efforts and activities to expand the core of research-based knowledge for nurses.

The nurse is expected to participate in the nursing profession’s efforts to implement and improve the standards of nursing care.

The nurse is expected to participate in the nursing profession’s efforts to maintain conditions of employment, including equitable socio-economic standards, which allow for delivery of high-quality nursing care.

The nurse is responsible for participating with the nursing profession in protecting the public from misinformation and misrepresentations.

The nurse is expected to participate and collaborate with other members of the health care team and community in promoting local and national efforts to meet the health care needs of the public.

The nursing profession is not to be taken lightly, nor to be entered into on a whim. Nurses render health care not only to the individual patients, but also to their families and to the community. Nurses are expected to coordinate the efforts of everyone involved to enhance the health and well-being of their patients. Nurses are responsible for respecting human rights. These include the right to life, the right to dignity, and the right to respect.

Nursing as a Profession

Nursing at all levels, whether you are an LPN, RN, or an APRN, is a profession. Achieving this status has been a hard-fought battle, but is one that all nurses must continue to fight with the goal to attract more capable young people into the profession. Nurses are overworked and underpaid. That is a fact, but salaries are increasing and work conditions are improving.

Professional Appearance

All nurses need to strive for maintaining a professional appearance at all times. Caps and white starched uniforms may be a thing of the past, but there is no excuse for not dressing appropriately. No matter what setting you work in, clean, professional attire must be worn. Wearing clean surgical scrubs and lab coats go a long way toward distinguishing men and women as health care professionals.

Gender issues cause male nurses to be mistaken for doctors and females accepted as nurses, even when they are doctors. Wearing identification tags and making a gentle correction could quickly clear up any misunderstandings. There is no reason to become indignant when people make incorrect assumptions.

Remember that you represent the nursing profession at all times—whether at work or at play. Your attire, hygiene, actions, and demeanor are always on display. This can be an intense responsibility and unfair at times, perhaps, but something you must be aware of. Would you want you taking care of your loved one?

In addition to representing the nursing profession, whether on or off duty, you represent your employer. How you appear and act reflects on the employer’s business. If you conduct yourself professionally and present a professional demeanor, you will command the respect you deserve from your employer, your coworkers, your patients, their families, and your community.

If you look and act the role, your patients will have much more respect for you as a professional. You will be better able to convince them that what you are telling them is in their best interest. You will gain your patients’ confidence and be better able to educate them and advocate for them.

Hair

Your personal grooming issues affect infection control. Having your hair fall into your field of vision in the middle of a procedure can be a cause for concern. Not only does hair falling in your face present the potential for you to make a mistake, but it can also contaminate your clean or sterile field. Having to brush your hair aside can cause you to break technique, contaminate yourself, or require you to remove yourself in the middle of a procedure to wash and re-glove. All these put you and the patient at risk.

Fingernails and Jewelry

The Centers for Disease Control