Culture Shock of the New Graduate RN

After two months of orientation as a Registered Nurse Intern (Graduate Nurse)on a Long Term Acute Care Unit, I've finally taken NCLEX and I'm finally beginning to face my culture shock.

The honeymoon is over. I'm beginning to ask myself whether I really want to be a nurse after all. Or, more truthfully,whether I really want to be a nurse at LTAC. Unit jumping would be very, very tempting right now. As the reality of the unit culture rubs itself in my face, I tell myself that there has to be a place where things are done more efficiently, more safely, more pleasantly. Maybe in E.R. Maybe in O.B. Maybe in Critical Care. Maybe at another organization altogether.

Then I remind myself that every healthcare job in every location has difficulties, a culture to adjust to, problems endemic to its staff and management. I tell myself that culture shock is a stage of my new life as an RN that I must pass through, I must weather. To jump ship right now from LTAC would merely delay the crisis that must come to me on the next unit. Until I come out the other side of the nursing culture shock (or become entirely broken in the process) I feel I must hold my course.

So I have pledged myself to remain in this position (unless God clearly intervenes) for at least 6 months, preferably the more appropriate 9 months from hire. I feel I ought not to do otherwise by my employer than give the work for which I was hired. I also feel that in doing so enough time will have elapsed to allow me to more accurately judge whether my distress is truly a product of this particular work environment or merely arises from the inevitable culture shock of the new graduate nurse.

What is it that troubles me, then, about my job? Since I have clearly indicated that I am troubled.

It is the constant sense of inadequacy and futility against the wave of human ailment that surges against me. It is the limitations of my memory and time management. It is the revulsion of my mind against tasks which I must perform, not because they are intrinsically valuable, but because they are printed on a sheet which I must sign. It is the panic of my conscience against the crush of time which prohibits the detailed inquiry, precaution, and care I have been trained to undertake.

I hesitate to be specific about the above. Much of the specifics do not make sense outside of the context. One must live in that context to understand and justify the apparent travesty.

The ideal world does not exist: for nursing no less than for any other profession. All day long we fight therapists for access to our patients. Can I do a dressing change for Mrs. Smith? No, Mrs. Smith is having occupational therapy. Can I take Mr. Joe's blood sugar? No, physical therapy is walking him in the hallway. Assessments, dressings, medications, treatments -- all are displaced by a rush of Physical Therapy, Occupational Therapy, Speech-Language Pathology, Respiratory Therapy, Hyperbaric appointments, Dialysis, X-Ray, Phlebotomists, Physicians, Families, Visitors... I am learning to be pushy and possessive of my patients.

And items kept where one needs them? Everyday, I have to call Pharmacy for something not sent up for a patient: from Vitamin C to Venofer, from Culturelle (basically yogurt pills) to Vancomycin (a top of the line antibiotic).

It is true, I am clumsy and not very quick. But this is the kind of work where one cannot afford to lose even a few minutes of the 12 hours one has to work with in a shift. I must strike a careful balance between deliberate double checking and prompt decisiveness. I cannot afford to overlook anything, and yet, I cannot afford the time it takes to identify every consideration.

Perhaps it is also discouraging that I work in a setting where the very nature of the patient body prevents me from receiving visible affirmation of the benefits of my efforts. As my preceptor frequently tells me, "These people are chronic." Many never regain their health completely; we keep them from worsening and help them learn to cope with their conditions. Frequently, we have patients for months at a time, some of whom ask me every day, "When can I go home?" We get the sickest of the sick -- not at the moment of crisis, but in the gradual decline brought on by years of self-abuse, lifestyle choices, or unfortunate genetic and physiologic tendencies. When everything has been done for them, they come to us, to finish out whatever we can do. While I don't have a statistic to back this up, my estimate is that one fifth of our patients will die in the next year. It seems that at least every month I hear of another patient I've interacted with at some point in the past year since starting to work at LTAC who has recently passed. And for a while, the morgue's vehicle seemed to be at least a monthly visitor.

Of course, these aren't all our patients. Many come to us for conditions that we can fix -- with time. These patients become stir-crazy and bored, even when they are getting better. As their wounds close in and heal, they become more and more anxious to leave, and more and more frustrated when they cannot yet. Yet, we do have some pleasant patients -- people who understand our limitations as well as their own.

For all of our patients, our work is important, thought it can be difficult to see this, or appreciate it. It is easy to become cynical with myself and my inability to provide for my patients what I feel is the best I can give. Yet, I must try. Every day that I work I must try. God will do what He wills with my work - and my culture shock.