Bull and Monkey/ graphite, charcoal, acrylic on vellum/by julianna paradisi

Bull and Monkey/graphite, charcoal, acrylic on vellum/by julianna paradisi

Julianna Paradisi, RN, OCN, writes a monthly post for this blog and works as an infusion nurse in outpatient oncology.

The culture shock experienced by new nurses making the transition from student to professional is well documented. Less well documented is the culture shock seasoned nurses face when changing jobs. Not all nurses are the same. Neither are all nursing jobs.

Working in an unfamiliar setting means being the new guy. You may have been in the top 10 of your nursing class for grades and clinical excellence. Or you may have held a position of leadership in your previous unit. In your new job, you are unknown and unproven.

For nurses changing jobs from high-acuity areas—ICU or bone marrow transplant, say—to an ambulatory clinic, the stress is twofold.

First, there’s a period of grieving the loss of hard-won skills and certifications that are not applicable in the new role.

Then there’s the shock that your skills and experiences did not prepare you for the outpatient setting. Often, the first realization is that high-acuity patients have central lines, so a nurse migrating from such a practice area may not have strong peripheral IV skills.

By contrast, placing peripheral IV’s is something outpatient infusion nurses do all day long; IV placement skills are learned over time through practice. The nurse experienced in high-acuity patient care is suddenly a beginner, often needing the help of coworkers to insert IV’s in patients. The inability to consistently start a peripheral IV is frustrating for the nurse and for coworkers, not to mention the patient.

I’ve been thinking a lot about how it feels to be new at a job, because of the changes at mine (see earlier post, “The ACA and Me: A Dispatch from the Trenches”). Although my job is basically the same job that it was, the oncology piece has greatly expanded, and I’ve worked hard to become familiar with numerous chemotherapy regimens.

Sometimes it feels like “See one, Do one, Teach one” all over again.

For instance, one of my new roles is phone triage. I sit in a small office answering patient phone calls and emails for prescription refill requests, symptom management, and other concerns. I think, to many nurses, sitting at a desk answering phones is a very easy job.

That’s not my experience. While my hands-on patient care in this role is limited to accessing ports, starting IV’s, and drawing labs, I need to summon every ounce of buried nursing knowledge and assessment skill. When this falls short, I search references for drug adverse effect information, because many home medications are unfamiliar to nurses working in clinical settings. This is important—patients may perceive their symptoms as adverse effects of drugs instead of a worsening condition.

Besides this, I verify that preauthorizations have been obtained, chase down busy doctors to sign prescriptions that can’t be sent electronically, assess patients over the phone, hoping I didn’t forget to ask a crucial question.

Meanwhile, the phone keeps ringing, the emails keep coming, and there are constant interruptions.

Then an oncologist pokes his head in the doorway, requesting I provide chemotherapy education for a new patient. This means I have to let go of the ringing phones, and the concerns swirling in my brain. I put on my calm nurse face.

I enter the exam room, and introduce myself to a patient who just found out they have cancer. I see the fear in his or her eyes.

In that moment, nothing else exists.

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