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Seasoned with Sage
The Right Ward for New Grads

Over the last few years I've seen many new graduate nurses get jobs in some pretty intensive areas of healthcare, such as theater/recovery, emergency room, intensive care, pediatrics, and neonatal, to name but a few.

The young graduates are all smiles and full of excitement at landing such interesting jobs. Of course, the units taking on new grads often provide extra time to orientate the new grads to the job.
But I can't help feel that in the long run they still miss out.

I don't want to go over old ground, but the best advice I would give to any new graduate who asks me where they should work is this: spend two years in a general medical ward.

Why?  Often the medical wards run at a slower pace than the surgical. Having a bit of extra time allows nurses to spend time with patients, to become comfortable in their environment, and become familiar with how a ward should be run.

Comments such as "It's boring," "They're all old," or "It's not a challenge" are not uncommon amongst new grads when asked if they would like to work in a medical ward.

What they don't understand is that medical knowledge and skills apply to every other aspect of nursing.

Consider this: How often does a medical patient develop a surgical problem? Not often. Now consider how often a surgical patient develops a medical problem. I'm thinking about pulmonary embolism, Myocardial Infarction, DVT…the list is endless. Often surgical patients already have medical problems before going to theater.

The skills you learn in general medicine apply everywhere and will set you in good stead wherever you go. It's not the only way to do things--but you'd certainly not be harming your prospects by doing a little good old-fashioned groundwork.

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25 Responses to “The Right Ward for New Grads”

  1. RehabRN Says:

    I agree with you, but I started in a specialty, rehab nursing, so I got to see a lot of the things you describe in our patients, such as DVT, PE, etc.

    I worked with post-acute illness patients, post-trauma, post-surgical and post-transplant patients. I literally learned something new every day I worked and I had to do homework to learn a lot of this stuff. The trick is…find something new to learn every day wherever you are.

    Never become complacent. Complacency kills people.

  2. Megan Says:

    Thanks for the advice! I have heard a similar recommendation many times from professors, and now that I’m only a year away from graduating and finding a job, I’m taking this idea much more seriously. I think you’re probably right, and that’s where I’ll head first.

  3. A Critical Care RN Says:

    I actually disagree with this post. The director of a very prestigious university once told me… “why waste your time doing something you don’t want to do only to gain so called experience and then having a huge learning curve again once you move to the area you want and figuring out that only about a 1/3 of the information you learned the last few years is actually useful? Doctors never have a break in their education, they don’t take time off to all study family practice before moving on to critical care.” This also applies to a waiting period between applying to a masters program right out of school. As a new grad in the ER, I learned a lot and saw a lot very quickly. If you are capable of processing the information around you quickly, then by all means start in the high acuity area YOU want to start in. 100% of the information you learn will be applicable for the rest of your career because you’re in an area you want to be in and are not moving. The times of spending time on the floor are over as each area is becoming much more specialized (and yes, this includes the floor with equipment and skills that might never be practiced on the unit but are equally as complex). So after all this rambling, start where you want, get used to it, adapt quickly, ask for help, and you’ll be fine.

  4. paramedinurse Says:

    I agree but disagree with the primary post.
    I’m a newly graduated Rn (May 2008), but am not new to the medical field. I knew going into the nursing program that I was bound to work in an ED somewhere; I also knew that, due to state laws/standards, I would have to work somewhere else in the hospital for a year before I could work in the ED. I chose to work on a cardiac care/step-down unit (as opposed to the ICU)based on the suggestion of an ED nurse. I thought that it was a fast-paced floor and it would better prepare me to be able to handle multiple patients at a time. Having worked on the floor for 4 months now I can say I’m bored out of my mind!!
    I don’t feel that I’m using my critical care experience (ACLS & PALS certified as well as 4 years pre-hospital experience)- I feel I’m at the point that if I were to work at a 4 star restaurant I would be doing essentially the same job with less responsability and less poop!

    On the other hand, some the the new nurses I graduated with were either terrified at the thought of working in a critical care setting, or realized that they needed time on medical unit to strengthen their skills.
    I guess what it all comes down to is that each new nurse should sit down and really think about their experience and where they want to take their career and be able to work in the area that interests them.

  5. 1claudia Says:

    My view is that new grads should spend at least 1 year on a General Medical floor. During that year, assessment skills are developed as well as other nursing skills. Intensive care units have cardiac monitors that can lead new nurses to rely primarily on them. This is concerning since the basic nursing skill of observing the patient (not the monitor)is often omitted. I experienced this lack of looking at the patient and not the monitor on a monitored unit when I had a patient who a code blue was called on. The nurse who called the code saw asystole on the monitor and before checking the patient for a pulse called the code. I went running in and immediately looked at the patient and simulaneously checked for a pulse, then I looked at the monitor. The patient had a strong pulse.(the pt was on a vent and was sedated) I then checked the leads on the patient and found one disconnected. I think most of you know how embarrassed I was when the code team arrived and it was I who had to tell them it was a false alarm. (New Grads, that is not good.) I developed my assessment skills and the ability to look at patients and know something is seriously wrong when I worked on a General Medical Unit. I then moved onto other areas to include Telemetry, Step-down, ICU and now, ED. The skills I mastered while working General Medical have contributed to my success in those units.

  6. StudentRN Says:

    After reading through all this, I just want to say thank you very much for your concern for the new grads out there. We all appreciate it very much and reading these posts has helped shed some light on what option would be right for me this December.

  7. Kendra Says:

    I recently transferred to a new job in the cardiovascular ICU. we recover open heart, lung, and vascular surgeries right from the OR. I spent a year on their step-down telemetry unit before transferring to where I am now. I learned a great deal of organizational skills, plus how to prioritize and also learned how to react quickly and the right way in an emergency situation. I learned many invaluable lessons on that unit. I feel like I have a whole new field to learn now, though, and I almost feel like it would have been easier to start there from the beginning.

  8. Sarah Says:

    I have to disagree with this post. I appreciate the advice, but I’ve had several esteemed and respected professors say to me, “Never let anyone tell you you have to work on a general medical floor for a couple of years before specializing.” If you know exactly where you want to be, why not be there right from the start if you are able?

  9. Bryan J. Arwood Says:

    I totally believe in Specializing in an area. Medical Surgical floors are great place to train, but I think the ICU or ER is a better place for training.

  10. rnsocal76 Says:

    I wouldn’t still be a nurse after 6 years if I had started on a general med/surg. floor. I LOVED my experience of being trained, straight out of school as a neonatal ICU RN. Now it’s time to see other things. The E.R is next for me. Different city, different state, different specialty, in a unit that values my experience with infants and the versatility that I will be able to provide to the unit once I am comfortable in the new environment. I know a many drop-out nurses that listened to the “majority” and worked med-surg. right out of school. Now they’re back in school for something else because they didn’t go for what they were actually interested in doing. I understand the whole “experience” thing. But, what’s the point if you hate your job and end up quitting the career you went through hell getting your degree for? GO FOR WHAT YOU WANT TO DO. Carpe Diem! take it into your own hands to LOVE YOUR JOB!

  11. kathleen Says:

    Working on a floor is the right way to go. It is hard enough learning how to be a nurse in the real world. There is no need to learn how to be a nurse and learn a specialty at the same time. I know that floor nursing is terrible and stressful but that is needed for the foundation of nursing.

  12. Mr Ian Says:

    I like Bryn so I’m going to agree with him. But also cos I think he’s right.
    New grad nurses should develop slowly into the autonomous role and should also seek to keep their options open.
    I ‘specialised’ straight out of mental health training in forensics and really I could have done with some broader post grad experience. Mostly because after 15 years I know realise all I can do well is forensics – the rest is all basic. Same for nurses who specialise in say neonatal – when you want to progress to clinical manager – it’s gonna have to be in the pathway you’ve followed.

    I disagree with Critical Care RNs prestigious university director – nurses train generically over 3 years. Why not specialise from the start? Doctors also don’t just go into cardiology or paediatrics – they train generally and when they qualify – they rotate specialties. They become registrars or staff specialists after sampling many different arenas.

    Eventually it is necessary to stick to one thing or another but med/surg is the bread and butter of healthcare. It’s also a better way to learn everything else about nursing that your uni didn’t teach you.

  13. Shannon Says:

    I joined the AF being promised a new-grad position in the ICU. However- that didn’t happen and I landed a spot on our surgical inpt ward- where I spent 3 years. Looking back- I would not trade my “ward” experience for having gone directly into the ICU. I am of the opinion that most surgical patients are medical patients with surgical needs… so I don’t think you necessarily need to go to in inpt medical unit to get exposure to medical patients. Think about the little old lady who broke her hip in the middle of the night: we’d admit her under a medical team and ortho would only be her consult. Or what about patients with diabetes having amputations done. I don’t think “medical” is a necessary pre-req, because you get LOTS of medical on the surgical floor. That being said- I am in favor of time on a broad surgical floor (we had 13 surgical specialties on our ward)… rather than just vascular surg, gen surg, ortho/neuro… we had it all.

    Now- I’m working in the PACU- someplace I would have never thought to consider/ would have known I really like without having “done my time on the ward.”

  14. steubified Says:

    This is a subject on which nurses will always talk about but never agree upon. This is because we all have different goals and different ways of coming about those goals for ourselves. Some people step right out of nursing school into the field they want and they’ve always had a clear idea that this specialty/area/floor is always what they’ve wanted. Others go all through nursing school hoping to get some direction, but graduate with still no clear path. Perhaps the latter nurses would do better with some general experience while they figure out what they want to do from there. Perhaps the former nurses are better off taking the route of their chosen specialty right from the start. This decision is highly personal and isn’t one in which someone can really give advice about! Nurses will never agree on which approach is best, so let’s all agree to disagree.

  15. maleRN2009 Says:

    I disagree with you and here is why:

    When children are growing up and they say, “I want to be a astronaut”, no one tells them, ok, but you need to be a pilot first.

    It doesnt make sense…

    So why should someone who gets an education in the realm of nursing, get a state certified license that says they know what their job entails, comprehensively, why should that nurse not be allowed to pursue their dreams and find where they think they’ll fit best? After all, they made the decision to be a nurse for a reason.

    A nurse staffing recruiter from our HR once told, “Why would we put you somewhere that you don’t want to be? We want to try to accomodate you the best we can so that you can be happy to come and work for us.”

    And this is a hospital with one of the best employee retention percentages in the state of california.

    How dare you tell someone where they should work. This is AMERICA, for crying out loud.

  16. Mr Ian Says:

    maleRN2009: I can only hope you are either spoofing or you are still a little wet behind the ears.

    When children are growing up and dream of being the best – we humour them and their aspirations. We also apply a little realism to their dreams.
    AS for being a pilot before an astronaut – this is a route many take so it’s not unrealistic, tho not entirely necessary, to proffer that suggestion to a child.
    Similarly to take on the responsiblity of autonomously managing the highest care need and technically complex category of patients is doing two things:

    1. You are assuming that a newly qualified nurse is competent enough to do this job to the same grade as an experienced nurse.

    2. You are setting yourself up as elitist and dismissing ‘ordinary’ care as irrelevant to your progress and consolidation.

    Your nurse staffing recruiter was selling you something. Job satisfaction. It’s not their job to make you happy – it’s their job to fill posts.

    Would you let a newly qualified driver take the wheel of your Ferrari? They have the license to say they can drive….

    And by the way – this is the internet, not America. Hi from Australia.

  17. Lindsey Says:

    I am a new grad (May 2008) and am working in a very busy teaching hospital ER outside of Washington DC. Many people told me that it was not a good idea to jump into that environment right from school. I was nervous when I started and I know that I will ALWAYS be learning in the ER (and in nursing, for that matter) but I do not regret my decision at all.

    I am learning sharp assessment skills, communication skills, and how to be very thorough and efficient.

    I think it is empowering to go to the ER b/c you become very self-sufficient. We do our own IVs, labs, foleys, and breathing treatments. There is no stat team or code team – you are your own code team! You initiate standing orders and do not have to wait for the doctor to tell you that it’s ok.

    Our hospital is really great b/c the medical staff and nursing staff really are cohesive and not separate entities. MD’s help out and really respect the RN’s.

    I also think ER is a great place to go b/c you see a little bit of everything. You see diabetics, cancer patients, cardiac patients, GI problems, OB/GYN patients… you name it, it has come through the doors! Plus you get experience with patients of all ages.

    Looking back, I am so glad I chose ER b/c I know I will be a better nurse for it. It suits me and my personality. All in all though, I think it really does depend on the person. For instance, if you love being there to hold patient’s hands and spend a lot of time with them, ER is not for you! That’s why nursing is so wonderful – there is a type of practice for every nurse out there!

  18. bryn hagan Says:

    Ah Lindsey, I’m pleased for you but, I can’t help but notice that you concentrate on all the things you can do eg IV’s, Labs, Foley’s, breathing treatements etc. It’s normal for a new grad to be so task orientated, but it shows exactly just how new you really are.
    Over confidence kills just as surely as incompetence, be very careful.

  19. nurseeducator Says:

    I am a grad coordinator. I have seen both these things take place and have had many discussions regarding best practice for new grads. I think there is a place for general placements as this allows time for the basics to be bedded down. Specialist areas prefer nurses with some general experience as reported to me by ther NUM’s of these areas. The reason is that they tend to have more insight into patient care and better skills. There are always exceptions an I know of some outstanding nurses who progressed into these areas directly. Just don’t brand yourself as a particular type of nurse, be flexible and willing to change.

  20. A Critical Care RN Says:

    Hi Bryn, I think your post was extremely rude. I believe that Lindsey’s focus is not misplaced as tasks are often new grad’s biggest concerns. When it comes to ER, tasks are essential along with prioritizing patients. Time management is near impossible in the ER so mastering the above two skills will get you as close to time management as possible. I would love to know what makes a nurse a good nurse. It’s very unit based and as I said in my previous post, the time of learning the ropes on the floor is gone as each individual unit is becoming very specialized. Lindsey, I’m happy you started in the ER and are becoming proficient in it, keep working on it and I’m sure you’ll get far.

  21. bryn hagan Says:

    well, i’m sorry that an honest observation is considered rude. You just said youself that new grads are task orientated, same as me.
    As for specialized units, well, in 15yrs I’ve worked in med/surg, the first man in our gynae ward, ICU, CCU, psych, neonatal, paeds,temped in London for four years and covered nearly every single area they had to offer and I can honestly say that without a good solid base ie med/surg I’d be screwed. I can also say that it didn’t take me long to get the ropes in any new units/specialties that I came across because of a good solid background. In fact, my medical skills even came in handy in the psych ward as the staff turned to me whenever a psych patient developed a medical condition.
    Nurseeducator’s comment says it nicely, and that is that the units taking on new staff prefer someone with some general experience. There are exceptions, but it works out much better.
    Here’s an example of a new unit making a bit of mess of things:
    Mrs Smith, admitted via GP with history of PR Bleed. She’s stable at present. Her last bleed was twelve hours earlier and it was a lot of medium rare blood, not fresh, but not the tarry black stuff either. The new grad in the emergency room didn’t think to ask if she could get up to use the toilet unescorted. The patient leaves her bed and wanders to the toilets just outside the unit, in the corridor. The patient has another bleed. I notice her missing and the new grad tells me she went to the toilet. I run to toilet to find patient collapsed in toilet.
    The new grad feels terrible. To me anyone with basic general surg/medical experience would not make this mistake, at least not the girls I worked with.

  22. Lindsey Says:

    I wanted to clarify what I meant about the tasks. I meant that the tasks themselves become so routine that you can do them all without thinking and use each interaction with the person as an assessment… talking to the patient about their medical history while starting an IV, assessing breathing effort while doing EKG, etc…

    Becoming so proficient in “things” allows you to focus on the patient and not worry about being so focused on the task itself.

    I also really like having the docs right there as resources. It is nice to be a part of a place where the MD’s are very interactive with the nursing staff and the patients.

  23. A Critical Care RN Says:

    I think we all have heard or know the story of the patient who wandered to the bathroom and either went into respiratory arrest or bled out. I am not trying to be trouble maker but I fail to see the relevance to learning that on the floor. On the floor, patients have their own bathroom, they could very well wander into a bathroom and not be found for 2-4 hours depending on the last time they were seen, making the nurse feel REALLY bad. I think the mistake is better made in the ER (most ICUs don’t have bathrooms) because the time frame will be less and they are more adept to handle the acuity of the situation. A good preceptor like yourself, a strong charge nurse, and a good internship (3 month orientation at least) should be enough for a nurse to start on any unit they want. Stories like these should be passed on. Mistakes will be made on ANY unit, nurses will feel bad and suffer the consequences, all they can do though is chalk it up to a lesson learned.

  24. Laura Says:

    One problem I’ve heard seasoned nurses mention is is specializing right out of school to a unit where you only see a small set of problems. Psych, for instance, isn’t a place to develop your skills and “tasks.” You lose them. Babies aren’t small adults, and if the nurse wants to leave, they have to relearn adult problems.

    I’ve been told I shouldn’t have started in an ICU. I’ve also been told that starting a career in a rural, general ICU — we see everything from babies to adults with all sorts of problems — is perfect. Up on the floor, you can’t find a nurse to answer a question. They’re too busy to help! That would make me nervous. I always have someone around to answer questions. I can’t believe how much I’ve learned; it’s overwhelming how much I DON’T know, but I’ll get there.

    I spend 12 hrs with my patients. It helps me know them very well; I can see cause and effect of diseases, meds, and interventions. I would worry I’d miss something subtle if I was running between 6 pts. In the ICU, pts can crash fast and a monitor doesn’t always alert us to those subtle cues. I definitely use my assessment skills despite the monitors. If anything, I’m wary of them since they can be inaccurate so often.

    Bottom line to new grads: know yourself. Know how you learn, how fast you learn, the pace you want to work at, how many patients you can handle, how much time you want to spend with your patients. Tour the unit you are interviewing for and watch the staff interact!! Are staff helpful? Are they nowhere to be found? Are they happy, stressed, angry, caring? Good luck to all new grads, and do what makes you happy and keeps your patients safe.

  25. AmyJohnsonRN Says:

    I have to disagree with the original post. I feel like general med-surg floors are a great place to start out and learn and I’m sure if I would have started there I would have learned a great deal. However, I doubt that I would love my job like I do now. I started in an ED and I love it there, I’d never want to work on a regular floor, I feel like I learn something new everyday, I’ve been told my assessments are extremely well done, more so than need be (something I learned to do in nursing school is over assess) and I’m very happy wih my decision to specialize out of school.

    I think that if you know where you want to go, just go. You’ll learn everything you need to know in time whether you’re in the ED or on the floor, you just learn a little faster in some areas.

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