For newly licensed nurses, the transition can mean navigating unfamiliar clinical situations, making consequential decisions, and worrying about mistakes, often while working long shifts and adjusting to a new workplace.

“In school and clinicals, you’re never really the one holding it,” says Navjot “Navi” Hughes, PMHNP-BC, a psychiatric mental health nurse practitioner and founder of Empower Mental Health who previously spent eight years working in intensive care, progressive care, and emergency departments.

“The nurses don’t let you take over, so you graduate, and suddenly you are the one holding it, and it’s terrifying.”

That experience is often described as transition shock.

A systematic review and meta-analysis published this year in Nurse Education in Practice examined 31 studies involving 13,210 newly graduated nurses and found moderate levels of transition shock. Factors associated with the transition included self-efficacy, resilience, leadership, social support, the nursing work environment, and night shift frequency.

The research shows why telling new nurses to be more resilient is not enough.

When Stress Starts Following Nurses Home

Some anxiety and uncertainty are expected during the first year. New nurses are developing clinical judgment and confidence while caring for patients whose conditions can change quickly.

Hughes says the adjustment includes learning to remain grounded while being pulled in multiple directions.

“You constantly feel on edge, because you might miss a lab, you might miss a phone call, you might miss something important, and somebody’s life depends on it.”

The question is when expected first-year stress becomes something more.

“Some anxiety is normal, but you can tell it’s tipped into something more when it starts following you home,” Hughes says.

That might mean nightmares, being unable to enjoy days off, or feeling emotionally absent while spending time with family.

“When it starts taking your sleep, your days off, and the parts of your life that have nothing to do with the job, that’s the sign your mental health is starting to suffer.”

Shebna N. Osanmoh I, PMHNP-BC, a board-certified psychiatric mental health nurse practitioner with Savant Care, says persistent insomnia, changes in appetite, depression, difficulty maintaining relationships, and increased alcohol use are among the signs that a nurse may need additional support.

“If you stop enjoying life altogether and feel depressed, you require support,” Osanmoh says.

Thoughts of self-harm require immediate professional help rather than waiting to see whether they improve with time.

A Bad Shift Doesn’t Have to Become “I’m a Bad Nurse”

For nurses still developing their professional identity, criticism, mistakes, and difficult patient interactions can become judgments about whether they belong in the profession.

Tim Shurr, MA, a human behavior expert and author of One Belief Away!, says new nurses can begin interpreting individual experiences as evidence about their overall competence.

“A patient’s anger becomes ‘I’m a bad nurse.’ A mistake becomes ‘I’m not cut out for this.’ Constructive criticism becomes ‘I don’t belong here,’” Shurr says.

He encourages nurses to separate what happened from what they decided the experience meant about them.

After a difficult encounter, that can mean asking: What happened? What did I make it mean about me? What can I learn or do differently?

The goal isn’t to dismiss criticism or avoid accountability.

“I made a mistake, and I can learn from it,” Shurr says. “I received criticism about something I can improve.”

If a clinical error occurs, the nurse still needs to follow appropriate reporting procedures, take corrective action, and learn from it. But Shurr says a mistake can provide information without becoming an identity.

Research published in Nurse Education in Practice this year also identified professional role development, organizational and interpersonal support, and psychological resources such as resilience and self-efficacy as important to the transition.

Small Skills Can Help, but So Can Sleep

Not every strategy for managing stress requires a lengthy intervention.

Osanmoh recommends brief breathing or grounding exercises during stressful shifts. Slow breathing with a longer exhale can take about a minute. A grounding exercise can involve deliberately noticing sights, physical sensations, and sounds in the immediate environment to redirect attention from racing thoughts.

But coping techniques cannot replace recovery.

Osanmoh says chronic sleep disruption can worsen anxiety, contribute to mood changes, and affect concentration and judgment, a particular concern for nurses making clinical decisions.

“I think sleep is a part of the work, not outside the work schedule,” he says.

Hughes also cautions newly licensed nurses against immediately filling their schedules with overtime.

After years in school, the chance to earn more can make extra shifts tempting. But nurses who are still learning may need more recovery time, she says.

“Your days off are meant for taking care of yourself, not picking up extra shifts.”

Her advice is straightforward: prioritize sleep, take breaks that allow for movement and recovery, and establish mental health support before reaching a crisis.

Shurr recommends creating a deliberate transition out of work mode, whether that means taking several breaths after leaving the hospital, listening to music during the drive home, or developing another routine that marks the end of the shift.

“You can care deeply without carrying everything home with you,” he says. “Compassion does not require emotional absorption.”

Can These Skills Make a Difference Before Burnout?

Some research suggests that structured support can improve measures of well-being among newly licensed nurses, but the evidence does not show that resilience training alone can prevent burnout.

One program built around those types of skills is MINDBODYSTRONG, an evidence-based cognitive-behavioral skills-building program designed to help nurses and other healthcare professionals strengthen coping and resilience, manage stress, and support mental health and well-being.

Research on the program has included newly licensed nurses as well as nurses experiencing mental distress. In a 2026 randomized controlled trial of 501 nurses, researchers compared mental health screening and referral with screening and referral plus an online version of MINDBODYSTRONG. Nurses in the intervention group had a significantly lower risk of burnout at six months. The group also showed greater reductions in anxiety and depression and improvements in healthy lifestyle beliefs and behaviors during follow-up.

In a quality-improvement project published in the Journal for Nurses in Professional Development, researchers incorporated resilience and well-being training into an existing nurse residency program. The project reported improvements in both measures among participating newly licensed nurses.

Even with support available, other research shows how difficult the early months can remain.

Another study, involving new graduate oncology nurses, evaluated a resilience program that included education, individualized goals, mentoring, and a support group. Resilience scores declined significantly during the first six months, along with measures of professional quality of life and the new-graduate experience. Communication and organizational skills improved by 12 months.

Those findings do not establish what would have happened without the intervention. Still, they underscore why support for newly licensed nurses may need to continue beyond initial orientation.

Shurr says nurses should learn psychological skills before they are overwhelmed. That includes learning to receive feedback without turning it into a personal verdict, recognizing when stress spills into the rest of life, and developing an identity that doesn’t revolve entirely around work.

Even so, those skills have limits.

“A new nurse should not be expected to compensate for understaffing, inadequate orientation, bullying, or an unsafe workplace through better self-talk,” he says.

Asking Questions Shouldn’t Feel Dangerous

One of the simplest protections for a new nurse may also be one of the most important: feeling safe enough to say, “I don’t know.”

Hughes says fear of appearing incompetent can prevent nurses from asking questions precisely when they need guidance most.

“Asking questions is what keeps your patient safe, and it’s what builds your competence instead of exposing a lack of it,” she says.

She says the best preceptors and managers want new nurses to learn. They let them reason through decisions while staying available to step in and provide guidance.

Osanmoh says psychological safety extends beyond a nurse’s confidence.

If nurses believe asking a question is risky, they may start guessing instead, which could affect patient safety.

Residency programs, managers, and preceptors therefore have a role that extends beyond teaching clinical skills. Reasonable assignments, accessible mentors, consistent feedback, and a workplace that welcomes questions can shape how successfully a new nurse transitions into practice.

The 2026 meta-analysis supports that connection, identifying leadership, social support, and the nursing work environment among the factors associated with transition shock.

When It’s Time to Get Professional Help

New nurses may believe that struggling means they aren’t tough enough for nursing. Yet persistent symptoms should not be treated as a test of whether someone belongs in the profession.

Osanmoh recommends professional support when anxiety, depressed mood, insomnia, or relationship difficulties persist for more than a couple of weeks or begin interfering with daily life. Reliance on alcohol to cope is another warning sign.

Friends and colleagues can provide valuable support, he says, but they are not substitutes for mental health treatment.

Hughes encourages nurses to seek help sooner rather than later, particularly following traumatic events, workplace violence, or a patient’s death.

“The sooner the better,” she says.

The first year of nursing is a learning period that extends far beyond clinical skills. New nurses also learn to handle uncertainty, recover from difficult shifts, accept feedback, ask for help, and build confidence without expecting to know everything immediately.

Healthcare organizations also have something to learn during that transition.

New nurses can develop skills to manage stress. But those skills work best in environments where nurses have the time, support, and psychological safety to develop into the clinicians they are still becoming.

But somewhere along the way, something changed.

In her book, Keeping Up With the Cruzes: Overcome the Bullshit and Design the Life You Want, Cruz recalls caring for a patient whose baby was stillborn. She performed the necessary clinical tasks, said the right things, and completed her documentation. But emotionally, she felt nothing.

“I was not heartless. I was drained. But I kept showing up and doing what needed to be done,” she writes.

Burnout hadn’t arrived through a single breakdown or dramatic turning point. It developed gradually, leaving her increasingly disconnected from a profession she once loved.

Cruz tried changing nursing specialties, adjusting her schedule, and finding positions that might offer a better work-life balance. She also tried familiar stress-management recommendations, including vacations and self-care.

None provided lasting relief.

“I think there’s a place for self-care, but you can’t exercise, meditate, or vacation your way out of being completely exhausted,” Cruz says.

Her experience raises a larger question: If self-care isn’t enough to prevent burnout, what actually helps nurses?

Research suggests that structured psychological interventions can help nurses manage stress and reduce burnout risk. But experts say the real answer also requires changes to the working conditions that contribute to exhaustion.

Why Self-Care Has Its Limits

For Cruz, burnout wasn’t primarily about poor leadership, inadequate compensation, or feeling unappreciated.

Her biggest challenges were scheduling, workload, and not having enough time to recover between shifts.

After leaving labor and delivery for what she hoped would be a less demanding position in mother-baby postpartum nursing, she discovered that the workload remained intense.

She often started a 12-hour shift caring for five mother-baby couples, discharged those patients, and admitted five more before her shift ended.

Staffing shortages were common, and Cruz often volunteered for overtime to help cover the gaps.

“The extra money was nice, but I was also contributing to my own burnout without realizing it,” she says.

Justinna Dixon, PhD, RN, a psychiatric nurse scientist and health policy researcher who is a postdoctoral fellow at the University of Pennsylvania, says individual factors shape how nurses experience and manage burnout. But workplace conditions often determine how much those strategies can accomplish.

“There are many factors that influence the presentation and management of burnout among nurses and other clinicians,” Dixon explains.

Those factors include physical and psychological health, social circumstances, staffing ratios, workplace resources, and broader organizational conditions.

Dixon says interventions addressing organizational problems offer the greatest potential for widespread improvements in clinician well-being.

The distinction matters because nurses may do everything recommended to manage stress while still working under conditions that make recovery difficult.

What Actually Contributes to Nurse Burnout?

Among the organizational factors associated with burnout, Dixon identifies workload and the resources available to manage it as particularly important.

“One of the strongest organizational factors that affect nurse burnout is their workload and the resources they have to handle it,” she says.

Insufficient staffing increases responsibilities and limits time for patient care. Inadequate equipment, technology, and support personnel create additional obstacles.

Dixon experienced those problems herself while working as a mental health nurse at a hospital where staffing shortages and insufficient safety precautions contributed to widespread dissatisfaction and turnover.

She recalls that most employees stayed fewer than six months.

High turnover also meant fewer experienced nurses were available to mentor new employees and provide essential onboarding education, perpetuating the staffing challenges.

Dixon says decades of nursing research have shown that adequate staffing matters for patient outcomes, nurse well-being, and retention.

Another concern is moral distress.

Dixon describes it as the psychological strain nurses experience when they believe they know the ethically appropriate action but encounter barriers that prevent them from taking it.

For nurses who know what patients need but lack the resources to provide appropriate care, repeated experiences of moral distress can contribute to burnout.

Encouraging those nurses to become more resilient does little unless the barriers preventing them from delivering care are also addressed.

Can Evidence-Based Strategies Help Nurses Manage Burnout?

Although individual coping strategies cannot resolve systemic workplace problems, certain psychological interventions may help nurses manage stress and protect their mental health.

Cognitive-behavioral approaches teach specific skills to identify unhelpful thinking patterns, respond to stressful situations, and develop healthier coping behaviors.

One example is the MINDBODYSTRONG Mental Fitness Program, a cognitive-behavioral skills-building intervention developed by Bernadette Mazurek Melnyk, PhD, APRN-CNP, FAAN.

A 2026 randomized controlled trial published in Worldviews on Evidence-Based Nursing examined whether adding an online version of the program to mental health screening and referral could improve outcomes among nurses at risk for mental health challenges.

The study enrolled 501 nurses across the United States. Participants received either confidential mental health screening and referral or those services combined with seven online MINDBODYSTRONG modules.

At six months, 37% of nurses in the intervention group met the study’s burnout threshold, compared with 52.9% who received screening and referral alone. The difference was statistically significant, representing approximately a 30% lower relative risk of burnout.

However, between-group differences in anxiety and depression scores were not statistically significant. The study also relied on self-reported outcomes, and the follow-up analysis included only 329 of the 501 randomized participants.

The findings suggest that structured cognitive-behavioral skills training may help reduce burnout. However, the study did not examine whether those benefits would persist in workplaces with excessive workloads, inadequate staffing, or other organizational challenges.

What Healthcare Organizations Can Change

For healthcare leaders seeking practical ways to reduce burnout, Dixon points to emerging findings from her research involving nurses in 10 U.S. states.

Preliminary survey results suggest that hospitals with lower reported nurse burnout also had higher percentages of nurses who observed administrative efforts to improve staffing, protect uninterrupted breaks, and provide more time for direct patient care.

The findings are observational and do not establish that those efforts directly caused lower burnout rates. However, Dixon believes they identify opportunities for healthcare organizations.

Some changes, such as improving staffing levels, may require substantial resources and long-term planning. Others may be more achievable.

Dixon identifies protecting nurses’ breaks from interruptions as one intervention that could help without requiring the same investment as major staffing changes.

Healthcare leaders can also examine how much time nurses spend providing direct patient care versus managing competing demands.

Cruz finds those concerns familiar.

“I think nurses have a responsibility to take care of themselves, set boundaries and recognize when they’re reaching their limits. But healthcare organizations have a responsibility to make sure their nurses have reasonable workloads, adequate staffing and enough time to recover.”

She also recognizes the challenges of delivering care around the clock.

“Patients don’t stop needing care because we’re exhausted. Babies don’t stop being born because we’re short-staffed. I don’t pretend to have all the answers,” Cruz says.

Dixon believes wellness programs and workplace improvements must happen together.

“I believe the best approach is for resilience and wellness programs to happen concurrently with addressing working conditions for staff,” she says.

Otherwise, nurses may perceive wellness initiatives as an attempt to shift responsibility for burnout onto employees.

For healthcare administrators, Dixon recommends a multilevel approach that addresses individual, organizational, and broader healthcare system factors rather than relying on resilience training alone.

Recognizing When It’s Time to Seek Support

For individual nurses, recognizing when occupational stress has become something more serious can be difficult.

Cruz spent years defining strength by her ability to keep going, no matter the circumstances.

“What I wish someone had told me earlier is that being strong doesn’t mean you have to keep pushing through everything. I spent 25 years being the calm one, the dependable one, the nurse who could handle whatever came her way. I thought that was strength. And for a long time, it was. Until it wasn’t.”

She eventually recognized that her ability to tolerate difficult situations had become part of the problem.

“Somewhere along the way, I confused being strong with being able to tolerate absolutely anything.”

For nurses experiencing persistent exhaustion, emotional detachment, or difficulty recovering between shifts, seeking support may be an important step.

That can include discussing workload concerns with supervisors, accessing confidential mental health services, seeking professional counseling, or exploring evidence-based stress-management programs.

Setting boundaries and recognizing personal limits can also help nurses determine whether their working conditions remain sustainable.

For some, protecting their mental health may ultimately mean changing roles, specialties, or workplaces.

When Leaving Nursing Becomes the Answer

Cruz spent years searching for a way to regain the fulfillment she once found in nursing.

She explored different clinical specialties and eventually tried positions outside traditional bedside care, including legal nurse consulting and IV vitamin therapy.

But the changes didn’t restore what she had lost.

In her book, Cruz describes gradually spending more time helping at her husband Ricky’s automotive repair business and less time searching for another nursing position that felt right.

The transition wasn’t sudden. She wasn’t simply leaving nursing. She was moving toward building something with her husband.

Looking back, Cruz believes nurses need to recognize that leaving a profession they once loved doesn’t invalidate the work they accomplished.

“I think we need to stop treating burnout as something nurses just need to become more resilient to overcome. Sometimes the problem isn’t that you aren’t strong enough. It’s that you’ve been strong for too long without enough time to recover.”

She also acknowledges that sometimes, despite every effort to make a career work, moving on becomes the healthiest decision.

“That doesn’t make you a failure. It doesn’t erase all the years you spent caring for others. I loved being a nurse for a long time. And then I didn’t.

Both things can be true.”

Cruz’s experience underscores why preventing nurse burnout requires more than encouraging individuals to develop better coping skills.

Research suggests that structured psychological interventions can help, while organizational improvements involving staffing, workloads, protected breaks, and workplace resources address some of the conditions contributing to burnout.

For nurses, recognizing when they need support is important. For healthcare organizations, ensuring that support extends beyond wellness programs is equally essential.

Protecting nurses’ mental health shouldn’t depend solely on how much more they can learn to endure.

She reviews the patient’s most recent urine drug screen, prescribed medications, prescription drug monitoring program information, previous note, and treatment plan. By the time the patient’s face appears on her screen, Minter wants her attention focused on the person, not the chart.

“That preparation is important because when the patient appears on my screen, I want to be able to listen rather than spend the visit reconstructing what happened since our last appointment,” Minter said.

As a psychiatric mental health nurse practitioner specializing in substance use disorder treatment, Minter cares for adults with opioid and alcohol use disorders, including patients with co-occurring psychiatric conditions. Much of that care happens through telehealth.

Her clinical days typically run from 8 a.m. to 5 p.m., with approximately 24 to 27 patients during a full day. Follow-up visits generally last about 20 minutes, while new evaluations take longer. Depending on a patient’s clinical needs and stage of recovery, appointments may occur weekly, every two weeks or, for a smaller number of stable patients, monthly.

“Although the pace can be busy, I try not to allow the volume of the day to make an individual patient feel reduced to a prescription,” she said. “Medication management is part of my role, but so are assessment, education, listening, safety planning and maintaining the therapeutic relationship.”

Learning to Assess Patients Through a Screen

Telehealth changes the environment in which Minter practices, but it does not eliminate the clinical information available to her. Some of her patients are employed and meet with her during lunch breaks, allowing them to remain engaged in treatment while managing work and other responsibilities.

During visits, Minter assesses substance use and cravings, medication effectiveness and side effects, mental health symptoms, safety concerns, and progress toward treatment goals. When appropriate and time allows, she also incorporates supportive psychotherapeutic interventions.

“One advantage of seeing patients regularly is that I get to know their baselines,” Minter said. “In telehealth, I pay very close attention to changes in patterns.”

She watches appearance, hygiene, behavior, facial expressions, speech, mood, and engagement. A change from a patient’s usual presentation can prompt further assessment.

“If someone who consistently arrives well-groomed suddenly appears noticeably unkempt, I want to understand what changed,” she said. “It could involve substance use, but it could also reflect depression, significant stress, instability at home, or another concern.”

A normally talkative patient who suddenly becomes quiet, or a typically reserved patient who becomes unusually talkative or activated, may also warrant a closer look.

Rather than assuming the cause, Minter assesses substance use, suicidal or self-harm thoughts, possible intoxication or withdrawal, overdose risk, and other psychiatric or medical safety concerns. She also considers whether the patient can continue to be safely managed at the current level of care.

Depending on what she finds, Minter may request an unexpected urine drug screen, increase individual or group therapy, recommend additional recovery supports or arrange a higher level of care.

“The goal is not to catch someone in a mistake; it is to recognize changes early enough that we can respond appropriately and protect their safety,” she said.

From Medical-Surgical Nursing to Addiction Treatment

Minter’s approach is grounded partly in the seven years she spent in medical-surgical nursing before moving into inpatient psychiatry and eventually becoming a psychiatric mental health nurse practitioner.

She credits that experience with strengthening her assessment skills and preparing her to manage medically complex patients and emergencies.

“That experience continues to shape the provider I am today because physical and mental health so often go hand in hand,” she said.

Her interest in mental health began much earlier. Growing up in New York, Minter remembers seeing people experiencing homelessness who appeared to be responding to people others could not see or hear. At the time, she assumed what she was witnessing was connected to substance use. She later came to understand the complexities of serious mental illness.

A psychiatric clinical rotation during nursing school confirmed her interest in the field. After developing the medical foundation she wanted, Minter transitioned to inpatient psychiatry and pursued her psychiatric mental health nurse practitioner education.

Her decision to focus on substance use disorder treatment was also informed by seeing the effects of substance use within families and close relationships.

“Before I understood addiction as I do now, I remember wondering, ‘Why can’t I help them stop?’” she said.

Education and clinical experience changed her understanding.

“Substance use disorder is far more complex than simply deciding to stop using,” Minter said.

Meeting Patients Where They Are

Patients come to Minter at different stages of recovery, and her approach starts with understanding where they are rather than imposing expectations about where they should be.

With new patients, she may intentionally begin the conversation with something unrelated to substance use, such as their children, a pet, or a sports team on their shirt. The goal is to establish rapport before moving into more difficult territory.

Then she often asks a simple question: “Why now?”

For someone who has used substances for years or previously attempted treatment, the answer can reveal what changed and what is motivating the latest attempt at recovery.

“That question often leads to the most vulnerable part of the conversation and helps me understand what matters to them,” Minter said.

When a patient continues to struggle with substance use, maintaining engagement becomes a priority.

“I want them to know, ‘I’m happy to see you, and I’m expecting to see you again next week,’” she said.

For patients who have been stable in recovery for months or longer, visits may shift toward coping skills, self-care, relationships, stressors, and sustaining recovery. At the same time, substance use and treatment continue to be monitored.

Co-occurring psychiatric conditions add another layer. Changes in depression, anxiety, trauma-related symptoms, or other psychiatric concerns can affect recovery, just as substance use can affect psychiatric symptoms. Treatment may involve medication changes, additional therapy, stronger recovery supports, or coordination with another mental health provider.

“The treatment plan may change, but the underlying approach remains the same: understand where the person is, determine what they need now, protect their safety and keep them connected to care,” Minter said.

Medication Is Treatment

Buprenorphine plays a significant role in Minter’s care of patients with opioid use disorder. The FDA-approved medication can reduce opioid cravings and withdrawal symptoms and help patients achieve the stability needed to engage more fully in treatment and recovery.

Minter wants nurses and other healthcare professionals to understand a distinction she still sees blurred in conversations about addiction treatment.

“One thing I wish more nurses and healthcare professionals understood is that medication for opioid use disorder is treatment, not a reward,” she said. “A patient does not have to prove that they deserve evidence-based treatment.”

She still encounters the belief that taking medications such as buprenorphine or Suboxone amounts to “replacing one drug with another” or “trading one addiction for another.”

“That misunderstands both medication and addiction,” Minter said. “Physical dependence can occur with many prescribed medications and is not the same as addiction. A patient taking buprenorphine as prescribed for opioid use disorder is receiving treatment for a diagnosed condition.”

For nurses, Minter said language and attitudes can influence whether patients remain engaged in care.

“Recovery does not have to mean being medication-free,” she said. “For some patients, medication is one of the tools that makes sustained recovery possible.”

Adapting to a Changing Drug Supply

As the substances patients encounter change, Minter’s assessments have had to evolve with them.

Polysubstance use is common in her practice, and patients do not always know everything they have been exposed to. Someone may report knowingly using one substance while a urine drug screen indicates exposure to others. Counterfeit pills are another concern because a product obtained as a familiar prescription medication may not contain what the patient believes it does.

Minter is also asking more questions about products available through smoke shops, convenience stores, and online, including kratom and concentrated 7-hydroxymitragynine, or 7-OH, products.

“Some patients perceive products sold legally or over the counter as inherently safer,” she said. “Accessibility does not necessarily mean a product is safe, non-addictive, or without significant risk.”

Instead of asking only what drugs a patient has used, Minter asks what the patient knowingly used and compares that history with the objective information available. She also specifically asks about products purchased from smoke shops, convenience stores, and online because patients may not think to include them when asked about drug use.

“We cannot limit our assessments to the substances we traditionally learned about in school,” she said. “Clinicians have to remain curious, stay educated about emerging substances, and continue adapting the questions we ask.”

When the Diagnosis Becomes a Label

For Minter, treating substance use disorder also means confronting the stigma patients may encounter in healthcare.

She hears from patients who say they have felt judged before receiving a full assessment, particularly when seeking care for pain, anxiety, or other symptoms and being perceived as medication-seeking.

“Having a substance use disorder does not mean someone cannot also experience legitimate pain, anxiety, ADHD, depression or another medical or psychiatric condition,” Minter said.

Her message to nurses is straightforward: “The diagnosis should inform our assessment; it should not replace it.”

Because nurses often spend significant time with patients, Minter believes they can influence whether a healthcare encounter reinforces stigma or helps dismantle it.

“Listen first. Ask questions. Be curious rather than judgmental,” she said.

At the end of an initial assessment, Minter tells patients some version of: “It was a pleasure meeting you, and I look forward to supporting you as safely and as well as I can while you are with us.”

“Sometimes reducing stigma begins with something that simple: making sure the person sitting across from you knows you’re glad they came,” she said.

Keeping the Door Open

When a patient returns to substance use, Minter’s first concern is safety. She assesses what happened, current substance use, overdose or withdrawal risk, psychiatric and medical concerns, and whether the patient’s current level of care remains appropriate.

But she also works to protect the therapeutic relationship.

“Recurrence of use tells me something needs attention; it does not tell me that the patient is undeserving of treatment,” Minter said. “I want patients to come back and tell me what happened rather than avoid treatment because they are afraid of disappointing me or being judged.”

One patient has stayed with her. She met him several years ago, early in her time with the practice. He had been in and out of treatment multiple times, and their early work together was rocky. He returned to substance use more than once and left treatment at times. Eventually, he came back.

“Each time, we welcomed him back,” Minter said. “We reassessed where he was, addressed what needed to change, and continued treatment without shaming him for what had happened.”

Today, she said, he has maintained his recovery, continued his education, and built greater stability in his personal life.

“That experience reminds me of what can happen when we don’t give up on someone simply because their recovery isn’t linear,” Minter said. “Sometimes our job is to hold the door open long enough for a person to become ready to walk through it again.”

What Nurses Considering Addiction Care Should Know

For nurses and nursing students considering psychiatric mental health or substance use disorder treatment, Minter recommends first understanding why they want to enter the field.

“The first thing I would probably ask is, ‘What makes you think you want to do this work?’” she said. “I would like to know what motivates them because, in this field, your motivation matters.”

She recommends developing strong psychiatric and medical assessment skills and learning about substance use disorders, withdrawal, overdose prevention, medications for opioid use disorder, harm reduction, co-occurring psychiatric conditions, and trauma-informed care. Clinical experience with people who have substance use disorders and learning from experienced clinicians can also help prepare nurses for the work.

Equally important, she said, is examining personal assumptions about addiction.

“You can know the pharmacology and still cause harm if the person sitting across from you feels judged.”

The field can be difficult, frustrating, and emotionally demanding. Progress can be slow, and patients may struggle again after months of stability.

“The work is tough, but nurses are tough too, so that makes it a fair fight,” Minter said.

Despite the difficult days, Minter remains grateful for the work.

“There are many days when I am technically at work, but it doesn’t feel like ‘work’ in the traditional sense because I know why I am there, and the work is meaningful to me,” she said.

Her advice to nurses considering the specialty comes back to the same principle that guides her own practice.

“If this is your field, you will know why you chose it. Hold onto that reason.”

Ready to Take the Next Step Toward PMHNP Certification?

If you’re preparing to become a psychiatric mental health nurse practitioner, Springer Publishing’s PMHNP Certification On-Demand Video Review Course provides focused exam preparation with digital access through ExamPrepConnect.

She studied vocal performance in college, spent her 20s working as a musician and actor, and performed in Miss Saigon on Broadway. When that chapter of her career ended in February 2001, Seligson was already thinking about what would come next.

“I had had a counselor that was very important to me in my early 20s; I wanted to emulate her and her positive impact on others’ lives, and I had had a long-running plan to go to graduate school for social work as my exit plan from the arts,” Seligson said.

That September, she started graduate school, earned her Master of Social Work from Hunter College, and eventually found her way into elder care.

There, she began noticing a pattern that would shape her career: People living with dementia were often misunderstood.

“They were blamed for things it seemed to me they could not help,” Seligson said.

She began researching dementia care and helped implement a dementia education program for staff, improving residents’ quality of life and transforming how staff understood their behavior.

“Just the concept that ‘behavior is how people with dementia communicate their needs’ is a huge paradigm shift, especially for the staff,” she said.

Today, Seligson is a dementia care specialist with Harmony Village at CareOne in New Jersey, where she works with residents, families, nurses, and other staff to provide individualized dementia care.

Looking Beyond the Behavior

For Seligson, caring for someone living with dementia begins with understanding the person rather than trying to correct the behavior.

“Well, first of all, the heart of my job, as I see it, is advocacy,” she said. “Advocating for persons living with dementia because they communicate their needs in a way that most people do not understand, through their behavior.”

Her job has three primary components: assessing residents and learning their histories and preferences, supporting families, and educating staff.

CareOne uses dementia educator Teepa Snow’s GEMS States model to assess residents’ stage of dementia. Seligson also learns each resident’s life story, likes, dislikes, and potential triggers, information that helps shape an individualized care plan.

Families are another important part of her work. She checks in with them, provides education, and helps them cope with the challenges of loving someone living with dementia.

“Sometimes they need to be given permission to step away and care for themselves without guilt,” she said.

Staff receive an initial full-day dementia class followed by monthly in-services, with education tailored to their roles. For nurses, Seligson said their close contact with residents gives them a particularly valuable perspective.

“The nursing team knows things that no one else does, because they help residents with the most intimate tasks possible- bathing, toileting, eating, sleeping, changing clothes,” Seligson said.

That proximity can help nurses recognize changes in cognition, physical function, and behavior before others do.

“One very important area that the nursing team usually notices before anyone else is a change in status of a person, either cognitively or physically, which is crucial so that the care plan can be adjusted to meet changing needs and ensure the person’s quality of life,” she said.

A Day Built Around Observation

Seligson typically begins her workday by checking in with the director of wellness, or director of nursing, to learn about any changes involving residents, families, or staff.

“If I can troubleshoot issues with residents, families, or staff, and keep those issues off of the DOW’s plate, it is my goal to do so before they even hear about it,” she said.

From there, she walks through the memory care neighborhood, greeting residents and checking in with staff. She reviews the electronic medical record for medical changes or new documentation and participates in a morning meeting with department heads.

Some of her most valuable assessment time, however, happens away from a desk.

Seligson tries to be present during meals because watching a resident eat can reveal changes that might otherwise be missed.

“Observing residents at mealtime can be a prime way to discover if someone’s dementia has progressed, and to demonstrate and teach changes that can be implemented in their care to make their life better,” she said.

A resident who previously used utensils independently, for example, may begin having difficulty using a fork. Instead of simply taking over the task, the care team can make adaptations, such as offering finger foods, that allow the resident to maintain as much independence as possible.

“We want to give needed support, but if we give too much support, we take away their agency and independence,” Seligson said.

She also helps serve meals, allowing her to interact with residents, work alongside staff, and model approaches to dementia care.

Her day may also include family meetings, formal care plan discussions, time spent alongside recreation and activities staff, resident reassessments, and documentation of behavioral concerns, interventions and family communication.

When a Resident Is Having a Difficult Moment

When a resident becomes anxious, confused, agitated, or resistant to care, Seligson first pays attention to how the person is being approached.

She said staff should approach from the front, establish visual attention before getting too close, speak slowly, and allow additional time for the person to process what is being said.

If the resident is distressed, Seligson looks for a possible unmet need.

“Do they have a need that is unmet? Are they hungry, thirsty, in pain, bored, tired, overstimulated, etc.,” she said.

The surrounding environment matters, too. Noise, movement, clutter, and other sensory input can contribute to anxiety, and sometimes moving to a calmer environment can help.

Seligson also cautions caregivers against trying to win an argument with someone experiencing dementia.

“I teach my teams- do not EVER argue, correct, or use reasoning or logic to try to de-escalate the person’s upset, because these approaches will only upset them MORE!” she said.

Instead, she focuses on empathy and emotional validation. If there is an identifiable need, the team can address it. If the source of distress is less clear, caregivers can offer emotional support and redirect the resident toward something personally meaningful.

That is where knowing the individual becomes essential. A resident’s family, profession, hometown, favorite music, and other life details can become tools for connection.

Dementia Care Is Team Care

Seligson’s social work training emphasized the person in their environment, the strengths perspective, and systems thinking, concepts she continues to apply in dementia care.

“I would say 75% of dementia related behavioral issues can be solved…not by changing the person with dementia, but by altering the environment,” she said.

That environment includes not only a resident’s physical surroundings, but also the people around them and how they interact with them.

Seligson also focuses on what residents can still do rather than only what dementia has taken away.

“If we can keep a person with dementia engaged in things they are still able to do, they are experiencing higher quality of life and fewer behavioral expressions of needs,” she said.

Doing that effectively requires collaboration among nursing, social work, recreation, dietary, environmental services, leadership and other members of the care team.

It can also require helping families understand when a resident’s needs have changed.

Seligson recalled working with the family of a resident who needed to move from a traditional assisted living setting into memory care. Such transitions can be difficult because family members may be grieving changes in personality, capacity, and family roles while their loved one is still physically present.

Her social work background helps her support families as they process those transitions.

“Slowly the family will evolve from feeling that moving their loved one into another level of care is a horrible admission of loss, and they move towards realizing that for a person living with dementia, what that person has is the here and now, this moment,” she said.

What Nurses Interested in Dementia Care Should Know

For nurses and other healthcare professionals considering dementia care, Seligson believes clinical knowledge is important, including understanding the brain and the functions affected by dementia.

But knowledge alone is not enough.

“You have to WANT to do it, you have to be viscerally drawn to it,” she said.

CareOne’s dementia specialists come from nursing, social work, physical therapy, occupational therapy, and speech therapy backgrounds, she said. The work requires listening, empathy, and a willingness to reconsider assumptions about residents and their care.

“Valuable experience includes anything that makes one humble enough to admit when you’re wrong and leave your ego at the door and just exist to support others!!” Seligson said.

For nurses, that can mean recognizing that a resident who appears resistant, agitated, or difficult may be communicating a need rather than simply acting out.

Sometimes the clue emerges during an ordinary part of the nursing day: a meal that suddenly becomes harder to eat, a familiar task that takes longer, an unexplained change in mood, or a resident who seems different.

Those observations can shift the question from what a resident is doing to what that resident may be trying to communicate.

Interested in a career in dementia care? Deepen your understanding of dementia caregiving and evidence-based interventions with Springer Publishing’s Handbook on Dementia Caregiving: Evidence-Based Interventions for Family Caregivers.

Sometimes those concerns are well founded. Other times, what appears to be a sudden decline in milk production reflects a normal change in lactation or a shift in feeding patterns, pumping routines, maternal health, or medication use.

Distinguishing perceived low milk supply from clinically significant reductions in milk production is an important part of breastfeeding assessment. Early evaluation can identify modifiable factors, reassure families experiencing normal changes, and help ensure that infants with inadequate milk intake receive timely support.

Milk production is a complex physiologic process influenced by frequent and effective milk removal, hormonal regulation, maternal health, medications, and breastfeeding management. The Academy of Breastfeeding Medicine recommends identifying and addressing underlying causes before turning to medications or herbal products intended to increase milk production.

For nurses, who often serve as a first point of contact for breastfeeding concerns in hospitals, pediatric and obstetric practices, outpatient clinics, and community settings, understanding those potential causes can help guide assessment and determine when additional evaluation is needed.

Is It Really Low Milk Supply?

Before investigating why milk production may be declining, nurses should first determine whether it has actually decreased.

Many breastfeeding parents interpret softer breasts, shorter feeding sessions, or lower pumping volumes as signs that their milk is “drying up.” As lactation becomes established, effective and regular milk removal plays an increasingly important role in maintaining production. Breasts may feel less full, while infants often become more efficient at feeding and can remove adequate milk in less time.

Pumping output can also fluctuate based on the time of day, recent feedings, pump performance, flange fit, and the individual response to pumping. An infant may remove milk more effectively than a breast pump, making the amount expressed during a single pumping session an imperfect measure of overall supply.

What matters more is the broader clinical picture.

Signs that an infant may not be receiving adequate milk include:

• Poor or slowed weight gain
• Fewer wet or dirty diapers than expected for age
• Persistent signs of hunger after most feedings
• Lethargy or excessive sleepiness during feeds
• Difficulty maintaining effective feeding sessions

When these signs are present, breastfeeding effectiveness and infant growth warrant further assessment. If an infant is gaining weight appropriately, producing adequate wet and dirty diapers, and appears satisfied after feedings, reassurance and education about normal lactation changes may be all that is needed.

Less Frequent or Ineffective Milk Removal

When milk supply has truly declined, one of the first places to look is how often and how effectively milk is being removed.

Milk production largely responds to demand. Frequent, effective milk removal supports continued production, while longer or more frequent periods of milk remaining in the breast can gradually signal the body to produce less.

Changes can occur for ordinary reasons. A patient returns to work. An infant begins sleeping longer overnight. Pumping sessions are missed. Family schedules change. Complementary foods are introduced. Over time, fewer opportunities for milk removal may translate into lower production.

Effectiveness matters as much as frequency. A baby may nurse regularly without transferring milk efficiently. Poor latch, shallow attachment, ineffective suckling, or positioning challenges can limit milk transfer even when the infant spends considerable time at the breast.

Nurses should therefore consider what happens during a feeding, not simply how often or how long the infant nurses.

Pump Problems Can Look Like Supply Problems

For patients who pump regularly, declining output may originate with the equipment rather than milk production.

Potential problems include:

• Incorrect flange size
• Worn valves, membranes, or tubing
• Inadequate suction
• A malfunctioning pump
• Pump settings that do not effectively stimulate milk ejection

Patients may assume their bodies are producing less milk when worn components or poor pump fit are actually reducing the amount expressed. Reviewing pump fit, function, and maintenance can therefore be an important part of assessing an apparent decline.

Supplementation and Schedule Changes

Formula or donor milk may be medically necessary in some circumstances, but when supplementation replaces breastfeeding without corresponding pumping or breast stimulation, milk production may decrease.

Abrupt schedule changes can have a similar effect. Returning to work without a pumping plan, extended separation from the infant, maternal or infant illness, hospitalization, or rapid weaning can all reduce opportunities for milk removal.

If continued breastfeeding is a goal, nurses can help patients understand how these changes may affect production and identify strategies for maintaining appropriate breast stimulation.

A Nursing Assessment Should Look Beyond Milk Volume

When a patient reports declining milk supply, the amount collected during a pumping session is only one piece of information.

A useful lactation history should consider:

• Feeding frequency over 24 hoursP
• Pumping frequency and duration
• Recent changes in work, sleep, or feeding schedules
• Changes in overnight feedings or pumping
• Latch and effectiveness of milk transfer
• Formula or donor milk supplementation
• Pump type, flange fit, and equipment performance
• Infant weight trajectory
• Wet and dirty diaper output
• Infant behavior during and after feeding

This assessment can help distinguish true low milk production from problems involving milk transfer, pumping, or normal changes in lactation.

Maternal Health and Hormonal Changes Can Affect Milk Production

If feeding and milk removal appear adequate, maternal health deserves closer attention.

Acute illness, hormonal changes, underlying medical conditions, and postpartum complications may affect lactation directly or make it more difficult to maintain a consistent feeding or pumping routine.

Illness, Fatigue, and Recovery

Patients who develop an illness, require hospitalization, experience significant pain, or recover from surgery may nurse or pump less frequently because they feel unwell. Hospitalization may also separate a breastfeeding parent from the infant and interrupt regular milk removal.

Severe sleep deprivation, physical exhaustion, and difficult postpartum recovery can create similar challenges. These factors do not necessarily suppress milk production directly, but they may make the routines necessary to maintain supply harder to sustain.

Nutrition and Hydration Matter, but More Isn’t Always Better

Patients frequently ask whether drinking more water or eating certain foods will increase milk production.

Adequate nutrition and hydration are important to maternal health during breastfeeding, and significant caloric restriction, dehydration, or poor nutritional intake may create problems. But consuming excessive amounts of water or particular foods has not been shown to increase milk production in otherwise healthy, well-nourished individuals reliably.

Nurses can help patients focus on adequate nutrition and hydration while avoiding common myths that promise a simple dietary solution to low supply.

Stress and Milk Ejection

Stress is also frequently blamed for declining milk supply, but the relationship is more nuanced.

Stress, anxiety, pain, and emotional distress may temporarily interfere with the milk ejection reflex, making milk more difficult to express during nursing or pumping. Patients may interpret lower pumping volumes or an infant’s frustration at the breast as evidence that production has suddenly fallen.

Stress may also contribute indirectly through missed feedings, shorter pumping sessions, fatigue, or disrupted routines. Helping patients understand that distinction can reduce unnecessary guilt while directing attention toward practical factors that may be addressed.

Hormonal and Medical Conditions May Require Evaluation

Persistent low milk supply despite frequent and effective milk removal may point to an underlying medical issue.

Potential contributing factors include:

• Thyroid disorders, particularly untreated hypothyroidism
• Polycystic ovary syndrome (PCOS)
• Diabetes or insulin resistance
• Significant postpartum hemorrhage
• Retained placental tissue
• Anemia
• Previous breast surgery affecting milk-producing tissue or nerves
• Insufficient glandular tissue
• Pregnancy during an ongoing breastfeeding relationship
• Mastitis or other inflammatory breast conditions

Some patients also report temporary fluctuations in milk production around the return of menstruation.

When milk production remains low despite appropriate breastfeeding management, nurses should consider whether symptoms or history warrant evaluation by an obstetric provider, primary care clinician, pediatric clinician, or International Board Certified Lactation Consultant (IBCLC).

Could a Medication Be Affecting Milk Supply?

When feeding patterns and maternal health do not fully explain a change in milk supply, medication use is another important part of the assessment. A new prescription, over-the-counter medication, hormonal contraceptive, or other product may coincide with a change in milk production.

Certain medications have been associated with reduced milk production or changes in lactation, but the relationship is rarely straightforward. Effects can depend on the specific drug, dose, timing postpartum, duration of treatment, stage of lactation, and individual response. The condition being treated may also influence breastfeeding.

For nurses, the question is not simply whether a medication appears on a list of drugs associated with decreased supply. The larger clinical question is whether medication use may be contributing to the change and how the patient’s treatment needs can be supported alongside breastfeeding goals.

Oral Decongestants

Products containing pseudoephedrine, a common oral decongestant, may reduce milk production in some breastfeeding patients. In a small study cited by LactMed, a single 60-mg dose was associated with a mean 24% decrease in milk production over the following 24 hours. Individual responses vary, but recent pseudoephedrine use is worth considering when evaluating an unexpected decline in supply.

Hormonal Contraception

Birth control is another frequent source of questions during the postpartum period.

Combined hormonal contraceptives containing estrogen and progestin have raised concerns about possible effects on lactation, particularly when initiated early postpartum. Evidence regarding their effect on breastfeeding outcomes is mixed, and postpartum timing is also important because of other maternal safety considerations. Progestin-only methods are generally more compatible with early postpartum breastfeeding, although contraceptive decisions should be individualized.

Contraceptive counseling should therefore consider breastfeeding goals alongside medical history, postpartum timing, and the need for effective contraception.

Certain Psychiatric Medications

Medications that reduce prolactin may interfere with milk production in some patients.

LactMed, for example, notes that aripiprazole can lower serum prolactin in a dose-related manner and has been associated with reports of decreased milk supply or lactation cessation.

That does not mean patients should stop psychiatric treatment because they are breastfeeding. Untreated mental health conditions can carry significant risks for both parent and infant, making coordination with the prescribing clinician essential.

Diuretics and Hormonal Therapies

Intense diuresis with high-dose diuretic therapy has historically been used as part of regimens intended to suppress lactation, although the contribution of the diuretic itself is uncertain. Effects vary by medication and dose, and lower therapeutic doses of some diuretics have not been shown to suppress lactation.

Some hormonal treatments and medications intentionally used to suppress lactation may also decrease milk production. As with other drugs, the potential effect depends on the medication, dose, treatment duration, timing, and individual patient.

Look Beyond the Medication

Timing alone does not prove that a medication caused a change in milk supply.

A patient taking an over-the-counter cold medication, for example, may also be ill, sleeping poorly, dehydrated, or nursing less frequently. Someone beginning contraception may simultaneously be returning to work or changing feeding schedules.

Examining the entire clinical picture helps nurses avoid attributing every change in milk production to a medication while still recognizing medication effects when they are plausible.

Most importantly, a possible effect on milk supply does not automatically make a medication inappropriate.

Treatment for depression, hypertension, thyroid disease, asthma, or another medical condition may be essential. Alternative therapies may sometimes be available, but medication changes should be made in collaboration with the prescribing clinician rather than by stopping treatment without guidance.

Herbs and Supplements Are Not Automatically Harmless

Patients concerned about low supply may also turn to teas, cookies, powders, gummies, and herbal supplements marketed to increase milk production.

Common ingredients include:

• Fenugreek
• Blessed thistle
• Fennel
• Goat’s rue
• Combination herbal blends

Although some herbal galactagogues have a long history of traditional use, evidence supporting their effectiveness remains limited. The Academy of Breastfeeding Medicine recommends evaluating modifiable causes of low supply and relevant medical factors before turning to herbal or prescription galactagogues.

“Natural” also does not mean risk-free. Herbal products can cause side effects or allergic reactions, interact with medications, and vary in quality and concentration. Unlike prescription drugs, dietary supplements generally do not undergo FDA premarket approval for safety and effectiveness.

For nurses, asking specifically about supplements is therefore an important part of medication reconciliation and lactation assessment.

When Patients Should Seek Additional Evaluation

Many milk-supply concerns can be addressed by identifying normal lactation changes or correcting problems with feeding, milk transfer, or pumping. Others require additional clinical evaluation.

Patients should be referred or evaluated when:

• The infant is not gaining weight appropriately.
• Wet or dirty diaper output declines.
• The infant is unusually sleepy, difficult to wake for feedings, or consistently appears unsatisfied after nursing.
• Breastfeeding is persistently painful or milk transfer appears ineffective.
• Milk supply drops sharply and remains low despite frequent and effective milk removal.
• Fever, breast redness, swelling, or worsening pain develops.
• A significant decline follows a medication or hormonal contraceptive change.
• Symptoms suggest thyroid disease, anemia, pregnancy, retained placental tissue, or another underlying condition.
• The patient is considering stopping medically necessary treatment because of concerns about breastfeeding.

Depending on the circumstances, care may involve the patient’s obstetric or primary care clinician, the infant’s pediatric clinician, a pharmacist, and an IBCLC.

Nurses Can Help Find the Cause Before Reaching for a Solution

When patients ask how to increase breast milk supply, the most useful first step may not be recommending a food, supplement, medication, or more aggressive pumping schedule. It may be determining why milk production appears to have changed in the first place.

That requires looking at the infant’s growth and intake, feeding effectiveness, pumping patterns, maternal health, hormonal factors, medications, supplements, and recent changes in routine.

For nurses, that broader assessment can help separate normal lactation changes from problems that require intervention while preventing patients from abandoning breastfeeding or medically necessary treatment based on incomplete information.

Clinical Resource for Medication and Lactation Questions

Medication-related lactation questions can be particularly challenging because determining whether a drug is compatible with breastfeeding is not always the same as determining whether it could affect milk production.

Hale’s Medications & Mothers’ Milk 2025-2026 provides evidence-based information on 1,300 drugs, diseases, vaccines, and syndromes encountered during breastfeeding. The reference includes lactation risk categories, pharmacology information, and clinical guidance to help nurses and other healthcare professionals evaluate medication use while balancing maternal treatment needs, infant exposure, and breastfeeding goals.

Whether assessing a new prescription, answering questions about birth control or cold medicine, or considering whether a medication could be contributing to declining milk supply, nurses can use Hale’s to review the available evidence and support informed clinical decision-making.

Before recommending that a patient discontinue a medication or begin a product intended to increase milk supply, review the available lactation evidence and coordinate care with the prescribing clinician.

Explore Hale’s Medications & Mothers’ Milk 2025-2026 for current, evidence-based guidance on medication use during breastfeeding.

For many new parents, one of the first questions after leaving the hospital isn’t whether breastfeeding is beneficial. It’s whether they can safely take the medication they need while continuing to breastfeed.

As new medications enter the market and more parents return to work soon after childbirth, questions about breastfeeding and medication safety have become increasingly common.

Medication questions, postpartum recovery, mental health concerns, returning to work, limited access to lactation support, and individual medical conditions can all shape a family’s feeding journey. For many parents, breastfeeding is not simply a personal choice. It is a clinical, emotional, and practical experience that often requires ongoing guidance.

For nurses, lactation consultants, pharmacists, and other healthcare professionals, National Breastfeeding Month is also a reminder that their role doesn’t end at hospital discharge. Ongoing education, reassurance, and evidence-based guidance can help families navigate breastfeeding long after they return home.

Why National Breastfeeding Month Matters

Established in 2011, National Breastfeeding Month brings together healthcare organizations, public health leaders, and community advocates to raise awareness about breastfeeding and strengthen support for breastfeeding families. The observance complements World Breastfeeding Week, held annually from August 1 through 7, which promotes breastfeeding worldwide.

Leading health organizations, including the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP), recognize that breastfeeding provides important nutritional and immunological benefits for infants while also offering potential health benefits for the breastfeeding parent. At the same time, both organizations acknowledge that breastfeeding is not always straightforward and that families often need ongoing support after leaving the hospital.

Parents may encounter challenges such as:

• Difficulty achieving a comfortable latch
• Concerns about milk supply
• Breast pain, engorgement, or mastitis
• Questions about pumping after returning to work
• Conflicting advice from healthcare professionals
• Concerns about taking prescription or over-the-counter medications while breastfeeding
• Anxiety, depression, sleep deprivation, or other postpartum health concerns
• Limited access to lactation specialists or community support

National Breastfeeding Month encourages healthcare professionals, employers, and communities to recognize these challenges while improving the systems that help families meet their breastfeeding goals.

Nurses Are Often the First Source of Breastfeeding Support

Whether they work in labor and delivery, postpartum care, pediatrics, primary care, or community health, nurses are often among the first healthcare professionals parents turn to with breastfeeding questions.

Their role extends far beyond encouraging breastfeeding. Nurses help parents understand what is normal, recognize concerns early, provide reassurance, answer questions, and connect families with additional resources when needed.

Depending on their role and practice setting, nurses may:

• Assess positioning, latch, and feeding effectiveness
• Help parents recognize signs that an infant is feeding well
• Identify concerns that warrant medical evaluation or referral to a lactation specialist
• Provide practical guidance about pumping and returning to work
• Encourage realistic feeding plans that fit each family’s circumstances
• Collaborate with prescribers, pharmacists, and lactation consultants when medication questions arise
• Support parents whose feeding plans change without judgment

Most importantly, nurses help create an environment where families feel heard rather than judged. Effective breastfeeding support respects patient autonomy and recognizes that informed feeding decisions look different for every family.

Medication Questions Shouldn’t Automatically Mean Breastfeeding Must Stop

Nearly every nurse who cares for postpartum patients has heard some version of the same question: “Can I take this medication and keep breastfeeding?”

For some parents, the worry begins with a new prescription. Others hesitate to seek treatment altogether because they’re afraid the medication could affect their baby. In some situations, recommendations to discontinue breastfeeding may be based on incomplete or outdated information rather than current evidence.

Questions about medication safety rarely have simple yes-or-no answers. Whether a medication is appropriate during breastfeeding depends on factors such as:

• The specific medication and dosage
• How much of the medication may transfer into human milk
• The infant’s age, health status, and gestational age
• The condition being treated
• Available treatment alternatives
• The parent’s breastfeeding goals

Equally important is evaluating the risks of leaving a maternal health condition untreated. Delaying treatment for infections, chronic illnesses, anxiety, depression, or other medical conditions may also affect both parent and infant.

Helping families understand these factors empowers them to make informed choices rather than fear-driven decisions.

Supporting Maternal Mental Health Is Part of Breastfeeding Support

Breastfeeding conversations should always include maternal mental health.

Postpartum depression, anxiety, sleep deprivation, and other mental health conditions can significantly affect feeding experiences and overall family well-being. Nurses are often among the first healthcare professionals to recognize when additional support is needed.

That support may include screening for postpartum depression, encouraging open conversations about emotional health, discussing medication concerns with the healthcare team, connecting families with behavioral health and lactation resources, and directing patients to trusted educational resources such as the U.S. Office on Women’s Health, which offers practical guidance on breastfeeding, pumping, common challenges, and finding lactation support.

Breastfeeding should never come at the expense of a parent’s physical or mental health. Supporting maternal well-being and supporting breastfeeding are complementary goals, not competing priorities.

Breastfeeding Support Doesn’t End at Hospital Discharge

For many families, the real questions don’t begin until they get home, when support may be less accessible than it was in the hospital.

Parents may struggle to establish pumping routines after returning to work, locate private pumping spaces, access follow-up lactation care, or find community support. In some areas, access to International Board Certified Lactation Consultants (IBCLCs) and breastfeeding resources remains limited.

That support doesn’t end when patients leave the hospital. Before discharge, nurses can help families prepare for common breastfeeding challenges, answer questions they may encounter at home, and connect them with follow-up resources before problems become barriers.

National Breastfeeding Month also highlights the importance of broader system improvements, including workplace accommodations, insurance coverage for lactation services, consistent clinical guidance, and equitable access to breastfeeding support.

Helping Nurses Answer One of Breastfeeding’s Most Common Questions

When patients ask whether a prescription medication, over-the-counter product, herbal supplement, vaccine, or medical condition is compatible with breastfeeding, clinicians need current, evidence-based information.

For more than three decades, Hale’s Medications & Mothers’ Milk has served as one of the most trusted clinical references on medication safety during lactation. The 2025-2026 Twenty-first Edition continues that tradition with updated evidence and expanded guidance for today’s clinical practice.

Written by Thomas W. Hale, RPh, PhD, and Kaytlin Krutsch, PhD, PharmD, MBA, BCPS, the manual helps nurses, lactation consultants, pharmacists, physicians, and other healthcare professionals evaluate medication use during breastfeeding using the latest available evidence.

The newest edition includes expanded guidance on medications that frequently generate questions from breastfeeding patients, including therapies for obesity, heart failure, anxiety, and postpartum depression. It also features Dr. Hale’s well-known Lactation Risk Categories, allowing clinicians to evaluate medication use while considering both maternal treatment needs and infant safety.

Rather than relying on outdated assumptions or unnecessarily recommending that breastfeeding stop, healthcare professionals can use current evidence to support individualized clinical decision-making and more meaningful conversations with patients.

Nurses and other clinicians looking for evidence-based guidance can learn more about Hale’s Medications & Mothers’ Milk 2025-2026 here.

Supporting Families Through Evidence-Based Care

National Breastfeeding Month is about more than encouraging breastfeeding. It’s about ensuring families have access to the clinical expertise, accurate information, and compassionate support they need to make informed feeding decisions.

Every family’s journey is different. By listening without judgment, addressing medication concerns with current evidence, supporting maternal mental health, and connecting patients with appropriate resources, nurses can make a meaningful difference throughout the breastfeeding journey.

For nurses, breastfeeding support has never been about having all the answers. It’s about listening, answering questions honestly, and helping families find trustworthy information so they can make the decisions that are right for them.

As new medications enter clinical practice, access to current, evidence-based lactation references becomes increasingly important. Resources such as Hale’s Medications & Mothers’ Milk 2025-2026 help clinicians answer those questions with confidence while supporting both maternal health and infant well-being

Fines Shaw, PMHNP was paid honoraria by Bristol Myers Squibb.

For many nurses and nurse practitioners, our profession begins in a classroom or clinical setting. For me, it began at home.  When my mother was 31, she was diagnosed with schizophrenia. Looking back, the time I spent as her care partner was formative for me, and the skills I learned through that experience became even more important when my daughter was diagnosed with schizophrenia.

Through my experiences as a care partner for both my mother and my daughter, I came to understand how misunderstood schizophrenia is.  The condition affects far more than the person diagnosed. It touches every aspect of daily life for families and loved ones as well.[i] Those experiences shaped me as a nurse and reinforced how important it is to listen and advocate for patients, and work alongside them to find the most appropriate care and treatment options.

My personal connection to schizophrenia didn’t just change my understanding of the condition – it changed my life. Prior to my daughter’s diagnosis, I had been working as an emergency room nurse. Once we learned her condition though, I knew I wanted to focus my efforts in the mental health space. Ultimately, I became a psychiatric and mental health nurse practitioner, which allowed me to advocate for others experiencing challenges, especially with schizophrenia. It also taught me empathy, gave me better insight into the needs of my patients and made me want to share my story in the hopes it helps other healthcare professionals in their practice.

Life as a Care Partner

From the time I was a child, I saw firsthand how schizophrenia could impact someone’s life, often bringing periods of instability and uncertainty. Over time though, I became more resilient and developed ways to better support someone living with schizophrenia – something that would prepare me, in unexpected ways, for motherhood.

When my daughter was in her teenage years, I noticed she was starting to isolate more. She eventually confided in me that she was experiencing a number of symptoms that were affecting her daily life. Although at times the uncertainty was overwhelming, I applied what I had learned through my mother’s experience and as a nurse to help my daughter find answers. It took time, and many healthcare professionals, before she received her diagnosis. It came with a mix of complex emotions, but we felt a sense of relief in having clarity. What grounded me throughout the process though was my commitment to be present: to listen, to learn, and to create a safe space where she could share her experiences without judgement.

I’m reminded that support and compassion are essential. Staying by someone’s side becomes a way of supporting and guiding them toward care, but it also can reaffirm one’s purpose.

My Past Shaping My Future

Searching for answers as a care partner was frustrating at times and often left me feeling helpless, but that uncertainty became a catalyst. When advocating for my daughter, I wanted to ensure that others facing similar challenges felt seen, heard, and supported.

Now as a mental health professional, I often reflect on my experiences and channel the concerns and challenges I faced as a care partner to inform every aspect of my practice. By remembering my own hesitation to ask questions and my unspoken fears, I’m able to understand what my patients may be experiencing under the surface and really use that to build trust and have open, honest conversations.

Between my formal training and personal connection to schizophrenia, I can recognize symptoms more quickly, communicate with greater empathy, and appreciate the importance of finding the right treatment for each individual to meet their unique needs.

COBENFY as a Treatment Option

My personal experiences helped me realize how critical nurses and nurse practitioners are in guiding patients with schizophrenia through their treatment journeys and gave me a deeper understanding of the responsibility we have in really listening and exploring different approaches based on their overall symptoms. For several of my adult patients living with schizophrenia, one of those approaches has been COBENFY (xanomeline and trospium chloride), a twice-daily oral medication for adults with schizophrenia.[ii]

It is not known if COBENFY is safe and effective in children. Please see Important Safety Information below and  U.S. Full Prescribing Information and Patient Information for COBENFY.

COBENFY is a unique combination of a xanomeline, a dual M₁– and M₄-preferring muscarinic receptor agonist, and trospium chloride, a muscarinic antagonist. Xanomeline binds to muscarinic receptors M₁ to M₅ with comparable affinity and exhibits higher agonist activity at the M₁ and M₄ receptors. Trospium chloride antagonizes the muscarinic receptors primarily in the peripheral tissues. Unlike other schizophrenia treatments, COBENFY does not bind to dopamine D₂ receptors. While the exact mechanism of action of COBENFY is unclear, selective M₁ and M₄ receptor activation is believed to modulate dopamine release. [iii]

The safety and tolerability profile of COBENFY has been demonstrated in over 1,250 patients across five clinical trials, including the short-term 5-week EMERGENT-1, EMERGENT-2 and EMERGENT-3 trials, and the long-term open-label 52-week EMERGENT-4 and EMERGENT-5 trials. The most common adverse reactions (≥ 5 % and at least twice placebo) in the short-term trials were nausea, dyspepsia, constipation, vomiting, hypertension, abdominal pain, diarrhea, tachycardia, dizziness, and gastroesophageal reflux disease (GERD). Additional adverse reactions include dry mouth, somnolence, blurred vision, salivary hypersecretion, orthostatic hypotension, cough and extrapyramidal symptoms (non-akathisia).

COBENFY has warnings and precautions for: risk of urinary retention, risk of use in patients with hepatic impairment, risk of use in patients with biliary disease, decreased gastrointestinal mobility, risk of angioedema, risk of use in patients with narrow-angle glaucoma, increases in heart rate, anticholinergic adverse reactions in patients with renal impairment, and central nervous system effects.

Please see Full Important Safety Information and U.S. Full Prescribing Information, including contraindications, below.

Where Lived Experience Meets Care

For me, bridging my lived experience with clinical practice is not just part of my profession; it’s the responsibility I carry into every patient interaction.

As both a nurse and a care partner, it’s important to me to share what I’ve learned about schizophrenia to help other healthcare professionals better connect with their patients and consider what they may be experiencing. It’s only then that we can truly understand their needs and help connect patients with the treatment option that is right for them. For appropriate patients, that treatment may be COBENFY.

Read more here about the importance of listening and connecting with your patients, and visit COBENFYHCP.com to learn more about COBENFY, including additional findings from the trials and resources to determine if COBENFY could be right for your patients.

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INDICATION 

COBENFY (xanomeline and trospium chloride) is indicated for the treatment of schizophrenia in adults.

IMPORTANT SAFETY INFORMATION 

CONTRAINDICATIONS
COBENFY is contraindicated in patients with:

• urinary retention
• moderate (Child-Pugh Class B) or severe (Child-Pugh Class C) hepatic impairment
• gastric retention
• history of hypersensitivity to COBENFY or trospium chloride. Angioedema has been reported with COBENFY and trospium chloride.
• untreated narrow-angle glaucoma

WARNINGS AND PRECAUTIONS 

Risk of Urinary Retention: COBENFY can cause urinary retention. Geriatric patients and patients with clinically significant bladder outlet obstruction and incomplete bladder emptying (e.g., patients with benign prostatic hyperplasia (BPH), diabetic cystopathy) may be at increased risk of urinary retention.

COBENFY is contraindicated in patients with pre-existing urinary retention and is not recommended in patients with moderate or severe renal impairment.

In patients taking COBENFY, monitor for symptoms of urinary retention, including urinary hesitancy, weak stream, incomplete bladder emptying, and dysuria. Instruct patients to be aware of the risk and promptly report symptoms of urinary retention to their healthcare provider. Urinary retention is a known risk factor for urinary tract infections. In patients with symptoms of urinary retention, consider reducing the dose of COBENFY, discontinuing COBENFY, or referring patients for urologic evaluation as clinically indicated.

Risk of Use in Patients with Hepatic Impairment: Patients with hepatic impairment have higher systemic exposures of xanomeline, a component of COBENFY, compared to patients with normal hepatic function, which may result in increased incidence of COBENFY-related adverse reactions.

COBENFY is contraindicated in patients with moderate or severe hepatic impairment. COBENFY is not recommended in patients with mild hepatic impairment.

Assess liver enzymes prior to initiating COBENFY and as clinically indicated during treatment.

Risk of Use in Patients with Biliary Disease: In clinical studies with COBENFY, transient increases in liver enzymes with rapid decline occurred, consistent with transient biliary obstruction due to biliary contraction and possible gallstone passage.  

COBENFY is not recommended for patients with active biliary disease such as symptomatic gallstones. Assess liver enzymes and bilirubin prior to initiating COBENFY and as clinically indicated during treatment. The occurrence of symptoms such as dyspepsia, nausea, vomiting, or upper abdominal pain should prompt assessment for gallbladder disorders, biliary disorders, and pancreatitis, as clinically indicated.

Discontinue COBENFY in the presence of signs or symptoms of substantial liver injury such as jaundice, pruritus, or alanine aminotransferase levels more than five times the upper limit of normal or five times baseline values.

Decreased Gastrointestinal Motility: COBENFY contains trospium chloride. Trospium chloride, like other antimuscarinic agents, may decrease gastrointestinal motility. Administer COBENFY with caution in patients with gastrointestinal obstructive disorders because of the risk of gastric retention. Use COBENFY with caution in patients with conditions such as ulcerative colitis, intestinal atony, and myasthenia gravis.

Risk of Angioedema: Angioedema of the face, lips, tongue, and/or larynx has been reported with COBENFY and trospium chloride, a component of COBENFY. In one case, angioedema occurred after the first dose of trospium chloride. Angioedema associated with upper airway swelling may be life-threatening. If involvement of the tongue, hypopharynx, or larynx occurs, discontinue COBENFY and initiate appropriate therapy and/or measures necessary to ensure a patent airway. COBENFY is contraindicated in patients with a history of hypersensitivity to trospium chloride.

Risk of Use in Patients with Narrow-angle Glaucoma: Pupillary dilation may occur due to the anticholinergic effects of COBENFY. This may trigger an acute angle closure attack in patients with anatomically narrow angles. In patients known to have anatomically narrow angles, COBENFY should only be used if the potential benefits outweigh the risks and with careful monitoring. 

Increases in Heart Rate: COBENFY can increase heart rate. Assess heart rate at baseline and as clinically indicated during treatment with COBENFY.

Anticholinergic Adverse Reactions in Patients with Renal Impairment: Trospium chloride, a component of COBENFY, is substantially excreted by the kidney. COBENFY is not recommended in patients with moderate or severe renal impairment (estimated glomerular filtration rate (eGFR) <60 mL/min). Systemic exposure of trospium chloride is higher in patients with moderate and severe renal impairment. Therefore, anticholinergic adverse reactions (including dry mouth, constipation, dyspepsia, urinary tract infection, and urinary retention) are expected to be greater in patients with moderate and severe renal impairment.

Central Nervous System Effects: Trospium chloride, a component of COBENFY, is associated with anticholinergic central nervous system (CNS) effects. A variety of CNS anticholinergic effects have been reported with trospium chloride, including dizziness, confusion, hallucinations, and somnolence. Monitor patients for signs of anticholinergic CNS effects, particularly after beginning treatment or increasing the dose. Advise patients not to drive or operate heavy machinery until they know how COBENFY affects them. If a patient experiences anticholinergic CNS effects, consider dose reduction or drug discontinuation.

Most Common Adverse Reactions (≥5% and at least twice placebo): nausea, dyspepsia, constipation, vomiting, hypertension, abdominal pain, diarrhea, tachycardia, dizziness, and gastroesophageal reflux disease. 

Use in Specific Populations:  

• Moderate or Severe Renal Impairment: Not recommended
• Mild Hepatic Impairment: Not recommended

Pregnancy and Lactation: There is a pregnancy exposure registry that monitors outcomes in women exposed to psychiatric medications, including COBENFY, during pregnancy. Healthcare providers are encouraged to advise patients to register by calling 1-866-961-2388 or visiting https://womensmentalhealth.org/research/pregnancyregistry/atypicalantipsychotic/.

There are no available data on COBENFY use in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage, or other adverse maternal or fetal outcomes. Additionally, there are no data on the presence of xanomeline or trospium in human milk, the effects on the breastfed infant, or the effects on milk production. However, xanomeline and trospium are present in animal milk, suggesting they may also be present in human milk. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for COBENFY and any potential adverse effects on the breastfed infant from COBENFY or the underlying maternal condition.

COBENFY (xanomeline and trospium chloride) is available in 50mg/20mg, 100mg/20mg, and 125mg/30mg capsules.

Please see U.S. Full Prescribing Information, including Patient Information. 

Cobenfy and the Cobenfy logo are trademarks of Karuna Therapeutics, Inc., a Bristol Myers Squibb company.

© 2026 Bristol-Myers Squibb Company.

1629-US-2600203  07/26

[i] Valery KM, Prouteau, A. Schizophrenia stigma in mental health professionals and associated factors: a systematic review. Psychiatry Research. 2020;290:113068.

[ii] COBENFY. Prescribing Information. Bristol-Myers Squibb Company; 2026.

[iii] Dean B, Bakker G, Ueda HR, Tobin AB, Brown A, Kanaan RAA. A growing understanding of the role of muscarinic receptors in the molecular pathology and treatment of schizophrenia. Front Cell Neurosci. 2023;17:1124333.

For nursing students and new nurses, understanding health policy helps explain how healthcare systems operate and how nurses can help improve them. Whether your career goal is bedside care, advanced practice, education, leadership, or research, a strong foundation in health policy can help you become a more effective advocate for your patients and profession.

What Is Health Policy in Nursing?

Health policy refers to the laws, regulations, organizational policies, and professional standards that influence how healthcare is delivered. These policies shape patient safety, workforce requirements, healthcare access, quality improvement, and public health.

Health policy exists at multiple levels, including:

• Federal policies that establish national healthcare laws and regulations.
• State policies that govern issues such as nursing licensure and scope of practice.
• Organizational policies developed by healthcare organizations to guide patient care and workplace practices.
• Professional standards created by nursing organizations that promote safe, ethical, and evidence-based practice.

Together, these policies create the framework for consistent, high-quality patient care.

Why Health Policy Matters to Nurses

Health policy affects nurses in every role and influences nearly every aspect of nursing practice.

Health policy influences:

• Patient safety requirements
• Staffing expectations
• Infection prevention protocols
• Documentation standards
• Scope of practice
• Access to healthcare services
• Quality improvement initiatives

As healthcare evolves, nurses are often among the first to recognize how policies affect patients, families, and care delivery. Their frontline experience gives them valuable insight into opportunities to improve healthcare systems.

Nurses Influence Policy More Than They May Realize

Many nurses assume influencing policy means lobbying legislators or running for public office. While some nurses choose those paths, policy influence often begins much closer to home.

Nurses help shape health policy every day by:

• Identifying opportunities to improve patient care
• Participating in quality improvement initiatives
• Serving on unit-based or organizational committees
• Helping develop or revise clinical policies
• Advocating for patients and families
• Participating in professional nursing organizations
• Sharing clinical expertise with healthcare leaders

These everyday contributions help improve care within healthcare organizations and can influence broader healthcare systems.

Nurses who want to explore health policy in greater depth can continue their learning with Nurses Making Policy: From Bedside to Boardroom, which explores practical strategies nurses can use to influence healthcare from bedside care to leadership roles.

Why Nursing Students Should Learn About Health Policy Early

Policy education is an important part of nursing education because it helps students understand the healthcare system in which they will practice.

A strong understanding of health policy can help future nurses:

• Better understand how healthcare decisions are made
• Strengthen patient advocacy skills
• Recognize opportunities for leadership
• Think critically about healthcare challenges
• Contribute to improving patient outcomes

As nurses advance throughout their careers, a foundation in health policy can also support leadership, education, quality improvement, and administrative roles.

Building Your Health Policy Knowledge

Learning about health policy doesn’t end after nursing school. As healthcare continues to evolve, nurses benefit from staying informed about the policies and decisions that shape clinical practice.

Many nurses continue building their knowledge through professional organizations, continuing education, graduate education, mentorship, and leadership opportunities. Staying informed about healthcare issues can help nurses become stronger advocates for their patients, colleagues, and communities.

Whether your goal is providing exceptional bedside care or eventually serving in a leadership position, understanding health policy can help you see the broader impact nurses have on healthcare.

Take the Next Step in Understanding Health Policy

For nurses who want to explore health policy in greater depth, educational resources can offer practical guidance on how nurses contribute to healthcare decision-making throughout their careers.

Nurses Making Policy: From Bedside to Boardroom explores how nurses can influence healthcare policy at every level—from direct patient care to leadership and advocacy. The award-winning, American Nurses Association-endorsed text combines actionable strategies, real-world case studies, and leadership insights to help nurses build the knowledge and confidence to advocate for patients, communities, and the nursing profession.

The Nurse Licensure Compact (NLC) can make it easier for eligible registered nurses (RNs) and licensed practical/vocational nurses (LPN/VNs) to practice in multiple participating states. For graduate nursing students pursuing advanced practice roles, however, it is also important to understand that RN licensure, APRN licensure, and national certification are separate credentials with different requirements.

What Is the Nurse Licensure Compact?

The Nurse Licensure Compact (NLC) is an agreement among participating U.S. states and jurisdictions that allows eligible RNs and LPN/VNs to hold one multistate license.

Instead of obtaining separate RN or LPN/VN licenses for every participating state where they want to work, eligible nurses with a multistate license may practice in other compact states without applying for additional licenses.

The National Council of State Boards of Nursing (NCSBN) administers the compact.

What Is a Multistate Nursing License?

A multistate license, sometimes called a compact license, is issued by a nurse’s primary state of residence if that state participates in the NLC and the nurse meets the compact’s uniform licensure requirements.

With a multistate license, nurses may practice in person or through telehealth in other participating compact states while following the nursing laws and regulations of the state where the patient is located.

Nurses do not automatically qualify for a multistate license. Eligibility depends on meeting the NLC’s uniform licensure requirements and establishing legal residency in a participating compact state.

Does the NLC Apply to Advanced Practice Nursing?

This distinction matters for graduate nursing students.

The Nurse Licensure Compact applies to RN and LPN/VN licenses. It does not provide multistate APRN licensure. An advanced practice registered nurse must meet the APRN licensure requirements for each state in which they practice.

NCSBN has also developed a separate APRN Compact for advanced practice registered nurses. However, APRNs should verify current licensure requirements with the board of nursing in each state where they intend to practice.

For graduate nursing students preparing to become nurse practitioners, this means they should view their RN license, APRN license, and national certification as separate credentials.

Licensure vs. Certification: What’s the Difference?

Licensure and certification are related but distinct.

State boards of nursing grant nursing licenses and determine whether a nurse is legally authorized to practice within a state. National certification demonstrates that an advanced practice nurse has met the requirements established by a national certification organization for a particular role and population focus.

For example, students preparing to become family nurse practitioners or adult-gerontology primary care nurse practitioners typically pursue national certification after completing their graduate education. Depending on their specialty and eligibility, they may take a certification examination administered by organizations such as the American Association of Nurse Practitioners Certification Board (AANPCB) or the American Nurses Credentialing Center (ANCC).

Understanding these distinctions becomes especially important for graduate nursing students planning to practice across state lines or provide telehealth services.

Why Should Graduate Nursing Students Understand the NLC?

Even if you plan to begin your advanced practice career close to home, understanding multistate RN licensure can be valuable as your career evolves.

It may be especially relevant if you:

• Plan to relocate after graduation
• Live near a state border and may practice in a neighboring state
• Are interested in telehealth
• Expect to maintain your RN license while pursuing or practicing in an advanced practice role
• Want greater geographic flexibility during your nursing career

Understanding which credential governs which part of your practice can help you navigate state requirements more effectively.

What If Your State Isn’t Part of the Nurse Licensure Compact?

Not every U.S. jurisdiction participates in the NLC.

If your primary state of residence is not an NLC member, you can still become a licensed nurse. However, you’ll generally need to obtain individual RN licenses for each state where you plan to practice as an RN.

Graduate nursing students preparing for advanced practice should also check the APRN licensure requirements in each state where they intend to practice.

Because compact participation and licensing requirements can change, verify current information with the appropriate state board of nursing and NCSBN.

Where Can Nursing Students Learn More?

NCSBN and the Nurse Licensure Compact provide resources to help nurses understand licensure requirements, including information about participating compact states, multistate license eligibility, interstate practice, and requirements for advanced practice nurses.

Graduate nursing students should also consult the board of nursing in any state where they plan to practice to determine the specific requirements for RN and APRN licensure.

Preparing for Nurse Practitioner Certification

For graduate nursing students pursuing family nurse practitioner or adult-gerontology primary care nurse practitioner roles, national certification is another important step on the path to advanced practice.

Maria T. Codina Leik, MSN, APRN, FNP-C, FNP-BC, AGPCNP-BC, is a nationally recognized advanced practice nursing educator whose FNP and AGNP Intensive Review resources are designed to help nurse practitioner candidates prepare for AANPCB and ANCC certification examinations.

Explore Maria Leik’s FNP and AGNP certification exam preparation resources from Springer Publishing as you prepare for the next stage of your advanced practice nursing career.

Understanding the differences among RN licensure, multistate licensure, APRN licensure, and national certification can help graduate nursing students navigate the transition into advanced practice with greater clarity.

Which nursing specialty is right for me?

With dozens of career paths available, from emergency nursing and critical care to pediatrics, oncology, labor and delivery, and community health, it can be difficult to know where to begin. Every specialty offers unique opportunities and challenges, and choosing your first job can feel like a decision that will shape your entire career.

The good news? It doesn’t have to.

Many nurses change specialties several times throughout their careers as they discover new interests, develop new skills, or pursue advanced education. Your first nursing position is an important step, but it’s only the beginning of your professional journey.

Quick Self-Assessment: Which Nursing Specialty Fits You?

Ask yourself these questions before you begin your job search:

✓ Do I enjoy fast-paced, unpredictable situations?

✓ Do I prefer building long-term relationships with patients?

✓ Am I energized by technology and complex clinical care?

✓ Do I enjoy teaching patients and families?

✓ Which clinical rotation did I look forward to the most?

✓ What type of work environment helps me do my best work?

Your answers won’t point to a single “perfect” specialty, but they can help you identify practice areas that align with your interests and strengths.

As you explore different nursing specialties, educational resources such as textbooks and clinical references can provide a deeper understanding of what day-to-day practice looks like in each field.

Why Choosing a Nursing Specialty Feels So Overwhelming

If you’re feeling uncertain, you’re not alone.

Unlike many professions, nursing offers an incredible variety of career paths. Some nurses thrive in fast-paced emergency departments, while others prefer building long-term relationships with patients in oncology, primary care, or hospice. Some enjoy the technical challenges of critical care, while others find fulfillment in educating patients and promoting wellness in community settings.

Because there are so many options, it’s easy to wonder whether you’re making the “right” decision.

The reality is that there is rarely one perfect answer.

Your first specialty should provide opportunities to strengthen your clinical judgment, develop confidence, and continue learning. As you gain experience, you’ll also gain a better understanding of the type of work environment, patient population, and pace that best fits your personality and career goals.

Many experienced nurses will tell you they never expected to end up in the specialty they love today.

Did You Know?

Nearly every experienced nurse can point to a moment when their career took an unexpected turn. Many begin in one specialty and later transition into another as they discover new interests, pursue advanced education, or take advantage of new opportunities.

One of nursing’s greatest strengths is the flexibility to grow and evolve throughout your career.

Questions to Ask Yourself Before Choosing a Specialty

Before comparing specialties, spend some time reflecting on what motivates you as a nurse. Your answers can help narrow your options and point you toward practice settings where you’re most likely to thrive.

What patient population interests you most?

Think back to your clinical rotations.

Were you energized while caring for children? Did you enjoy working with older adults? Were you fascinated by complex critical care patients, or did you find the greatest satisfaction in helping patients manage chronic conditions over time?

Your preferred patient population is often one of the strongest clues to finding the right specialty.

What type of work environment do you enjoy?

Every nursing unit has its own pace and culture.

Ask yourself whether you prefer:

• Fast-paced, unpredictable environments
• Structured routines
• High-acuity patient care
• Long-term patient relationships
• Team-based collaboration
• Independent decision-making
• Patient education and prevention

There are no right or wrong answers—only preferences that may make one specialty a better fit than another.

How do you handle stress?

Some specialties require rapid decision-making and constant multitasking. Others allow more time for patient education, discharge planning, or relationship building.

Understanding how you perform under pressure can help you choose a practice area where you’ll feel challenged without becoming overwhelmed.

What are your long-term career goals?

Think beyond your first job.

Would you eventually like to become:

• A nurse practitioner?
• A nurse educator?
• A clinical nurse specialist?
• A nurse leader or manager?
• A researcher?
• A travel nurse?

Some specialties naturally provide experience that supports these career paths, making it worthwhile to think about where you’d like your nursing career to take you over the next five to ten years.

Compare Common Nursing Specialties

Every nursing specialty offers a unique combination of pace, patient population, work environment, and career opportunities. The snapshots below provide a quick overview to help you compare your options.

Medical-Surgical Nursing

Best for: Building broad clinical skills and gaining experience across a wide range of patient conditions

Typical setting: Hospital inpatient units

Common certification: Certified Medical-Surgical Registered Nurse (CMSRN)

Emergency Nursing

Best for: Nurses who thrive in fast-paced environments and enjoy rapid decision-making

Typical setting: Emergency department

Common certification: Certified Emergency Nurse (CEN)

Critical Care Nursing

Best for: Caring for high-acuity patients and managing advanced technologies

Typical setting: Intensive care unit (ICU)

Common certification: Critical Care Registered Nurse (CCRN)

Pediatrics

Best for: Nurses who enjoy caring for infants, children, adolescents, and their families

Typical setting: Children’s hospitals, pediatric units, and outpatient clinics

Common certification: Certified Pediatric Nurse (CPN)

Oncology Nursing

Best for: Building long-term relationships while caring for patients undergoing cancer treatment

Typical setting: Cancer centers, infusion clinics, and hospital oncology units

Common certification: Oncology Certified Nurse (OCN)

Labor and Delivery

Best for: Supporting women and families through pregnancy, childbirth, and postpartum care

Typical setting: Labor and delivery units and birthing centers

Common certification: Inpatient Obstetric Nursing (RNC-OB)

Psychiatric-Mental Health Nursing

Best for: Nurses interested in behavioral health, therapeutic communication, and mental wellness

Typical setting: Behavioral health hospitals, psychiatric units, and community mental health centers

Common certification: Psychiatric-Mental Health Nursing Certification (PMH-BC)

Community Health Nursing

Best for: Prevention, patient education, and improving the health of entire communities

Typical setting: Public health departments, community clinics, schools, and home health agencies

Common certification: Advanced Public Health Nursing–Board Certified (PHNA-BC)

Once you’ve identified one or two specialties that interest you, consider exploring textbooks and clinical references in those practice areas. Reading beyond what you learned in nursing school can deepen your understanding of the patient populations, procedures, and clinical decision-making involved in day-to-day practice. Springer Publishing’s nursing collection includes specialty-specific textbooks, certification resources, and clinical references across more than 20 nursing disciplines.

Career Tip

Your first nursing job is a starting point—not a lifelong commitment.

Many experienced nurses work in several specialties throughout their careers. Every role helps you build clinical judgment, communication skills, and professional confidence that can open doors to new opportunities later.

Which Nursing Specialty Fits Your Personality?

Clinical skills can be learned. Personality is much harder to change.

That’s why choosing a nursing specialty isn’t just about the patient population—it’s also about finding a work environment where you can perform at your best.

While no nurse fits neatly into a single category, thinking about your natural strengths and preferences can help narrow your options.

If you enjoy variety and thinking on your feet…

You may thrive in emergency nursing, where every shift brings new patients, unpredictable situations, and opportunities to make rapid clinical decisions. Emergency nurses often care for patients of all ages and conditions, requiring strong assessment skills and the ability to prioritize quickly.

If you enjoy solving complex clinical problems…

Critical care nursing may be a good fit.

ICU nurses care for some of the hospital’s sickest patients while managing advanced technologies such as ventilators, invasive monitoring devices, and life-support equipment. The specialty rewards nurses who enjoy critical thinking, attention to detail, and continuous learning.

If you enjoy building long-term relationships…

Specialties such as oncology, rehabilitation, hospice, and primary care often allow nurses to develop lasting relationships with patients and families while supporting them through ongoing health challenges.

If you enjoy teaching and prevention…

Community health, public health, school nursing, diabetes education, and primary care frequently emphasize patient education, disease prevention, and helping people manage chronic conditions before they become more serious.

If you enjoy working with children and families…

Pediatric nursing combines clinical expertise with communication skills tailored to children at every stage of development while partnering closely with parents and caregivers.

The right specialty isn’t necessarily the most exciting or the highest paying—it’s the one where your strengths allow you to provide your best care while continuing to grow professionally.

Consider Your Lifestyle Along With Your Career Goals

Your work environment influences far more than your daily responsibilities. It also affects your schedule, work-life balance, stress level, and long-term career satisfaction.

As you compare specialties, consider questions such as:

• Am I comfortable working nights, weekends, and holidays?
• Do I enjoy the variety of 12-hour hospital shifts, or would I prefer a more predictable weekday schedule?
• Do I thrive in high-pressure situations, or do I perform best in calmer environments?
• How important is schedule flexibility?
• What type of workplace culture helps me succeed?

These questions don’t have right or wrong answers.

For example, some nurses love the intensity and teamwork found in emergency departments or intensive care units. Others find greater satisfaction in outpatient clinics, community health, hospice, or school nursing, where schedules may be more predictable and patient relationships often develop over time.

Burnout remains a challenge across healthcare, making it important to choose a specialty that aligns not only with your clinical interests but also with the way you prefer to work.

Questions to Ask During a Nursing Job Interview

Choosing a specialty isn’t just about the job title—it’s also about finding the right employer. Consider asking:

• Is there a formal nurse residency or transition-to-practice program?

• How long is orientation?

• What mentorship opportunities are available?

• What is the typical nurse-to-patient ratio?

• Are specialty certifications encouraged or reimbursed?

• What continuing education opportunities does the organization provide?

Asking thoughtful questions can help you determine whether an organization will support your growth as a new nurse.

Don’t Let Salary Be Your Only Guide

It’s natural to compare salaries when evaluating different nursing specialties. Compensation is an important consideration, especially for new graduates beginning their careers.

However, salary tells only part of the story.

Higher-paying specialties may involve overnight shifts, frequent weekends, emotionally demanding patient populations, or high-acuity clinical environments. Shift differentials, certifications, geographic location, years of experience, and employer also influence earning potential.

Instead of asking, “Which specialty pays the most?” consider asking: Which specialty will help me build the career I want?

Finding work that aligns with your interests often leads to greater professional satisfaction, stronger performance, and long-term career growth.

Which Nursing Specialties Are in Demand?

The demand for registered nurses remains strong across the United States, driven by an aging population, increasing healthcare needs, and workforce shortages in many practice areas.

While hiring needs vary by region and employer, hospitals and healthcare systems continue recruiting nurses in specialties such as:

• Medical-surgical nursing
• Emergency nursing
• Critical care
• Behavioral health
• Perioperative nursing
• Long-term care
• Home health
• Labor and delivery

Rather than focusing solely on current hiring trends, think about where you’ll have opportunities to continue developing your clinical skills.

Healthcare is constantly evolving. Nurses who build a strong clinical foundation and commit to lifelong learning often have the greatest flexibility to pursue new specialties as their careers progress.

Your First Nursing Job Doesn’t Define Your Career

Perhaps the biggest misconception among new graduates is that choosing a first specialty means choosing a lifelong career. It doesn’t.

Many experienced nurses have worked in several specialties before finding the one they love most.

A nurse might begin in medical-surgical nursing, transition into critical care, later become a flight nurse, and eventually move into education or leadership. Another may start in pediatrics before pursuing graduate school and becoming a pediatric nurse practitioner.

Every role builds transferable skills.

Communication.

Clinical judgment.

Patient assessment.

Time management.

Interprofessional collaboration.

These competencies become valuable no matter where your career takes you.

Rather than searching for the “perfect” first job, look for an opportunity that will challenge you, strengthen your confidence, and provide a supportive environment for learning.

A strong foundation during your first few years of practice can open doors throughout your career.

Think About Certification Before You Need It

When you’re graduating from nursing school, certification may feel like something to think about years down the road. In reality, understanding certification pathways early can help you make more informed career decisions from the very beginning.

Most specialty certifications require nurses to gain clinical experience before becoming eligible to sit for an exam. Understanding what these certifications require can help you identify the knowledge and skills you’ll develop as you gain experience in your chosen specialty.

For example:

• Emergency nurses often pursue the Certified Emergency Nurse (CEN) credential.
• Critical care nurses may earn the Critical Care Registered Nurse (CCRN) certification.
• Oncology nurses can pursue the Oncology Certified Nurse (OCN) credential.
• Pediatric nurses may work toward becoming a Certified Pediatric Nurse (CPN).

While certification isn’t required for every nursing position, many employers value specialty credentials because they demonstrate advanced clinical knowledge and a commitment to professional growth. Some organizations also offer salary incentives, clinical ladder advancement, or leadership opportunities for certified nurses.

Understanding these pathways early allows you to build experience intentionally and prepare for future milestones throughout your career.

As you advance professionally, specialty textbooks, evidence-based clinical references, certification review guides, and practice exams can help reinforce your knowledge and prepare you for certification. Springer Publishing’s nursing collection includes resources that support nurses from nursing school through specialty certification and continuing professional development.

Frequently Asked Questions

What is the best nursing specialty for new graduates?

There isn’t one “best” nursing specialty for every new graduate. The right choice depends on your interests, preferred work environment, personality, career goals, and learning style. Many nurses begin in medical-surgical nursing because it provides broad clinical experience, while others enter nurse residency programs in specialties such as critical care, emergency nursing, or labor and delivery.

Can new graduate nurses work in the ICU?

Yes. Many hospitals offer nurse residency or transition-to-practice programs that prepare new graduates for critical care nursing through structured orientation, mentoring, simulation training, and ongoing education. Requirements vary by employer.

Is medical-surgical nursing still a good place to start?

For many nurses, yes.

Medical-surgical nursing provides exposure to a wide variety of patient conditions, medications, procedures, and clinical skills. That broad foundation can make it easier to transition into other specialties later in your career. However, it isn’t the only path. Many healthcare organizations now offer residency programs that allow new graduates to begin directly in specialty practice.

Which nursing specialty pays the most?

Compensation varies based on geographic location, employer, years of experience, certifications, education, shift differentials, and demand. While salary is an important factor, choosing a specialty based solely on earning potential may not lead to long-term career satisfaction.

How often do nurses change specialties?

It’s common for nurses to work in multiple specialties throughout their careers. Skills developed in one practice area—such as communication, clinical judgment, patient assessment, and teamwork—transfer well to many other settings.

What if I choose the wrong specialty?

There’s good news: very few nursing career decisions are permanent.

Many nurses discover new interests after gaining bedside experience and successfully transition into different specialties, leadership roles, education, informatics, research, case management, or advanced practice nursing.

Your first nursing position is an important learning experience—not a lifelong commitment.

Your Next Step

Choosing your first nursing specialty is an exciting milestone, but it’s only the beginning of your professional journey.

Rather than trying to find the perfect specialty, focus on finding a role where you’ll continue learning, developing clinical confidence, and building a strong foundation for the future. As your interests evolve, nursing offers remarkable flexibility to explore new specialties, pursue advanced education, earn specialty certifications, and take on leadership opportunities.

No matter where your career begins, investing in your professional development can help you prepare for what’s next. Exploring trusted nursing textbooks, clinical references, certification review materials, and exam preparation resources can help you build the knowledge and confidence to grow throughout your career.

Whether you’re preparing for your first nursing position or planning your next professional milestone, the knowledge you build today will continue to serve you throughout your career.

Continue Your Nursing Journey

Ready to take the next step? Whether you’re preparing for the NCLEX, exploring a specialty certification, or deepening your clinical knowledge, Springer Publishing offers study guides, certification review materials, and digital exam preparation tools to support every stage of your nursing career.

Springer Publishing offers resources for every stage of the nursing journey, including:

Start Your Career

• NCLEX resources
• Nursing textbooks
• Clinical references

Advance Your Practice

• Certification study guides
• Practice questions
• ExamPrepConnect

Keep Growing

• Professional development
• Advanced nursing texts
• Specialty references

Ready to learn more? Explore Springer Publishing’s nursing collection to discover textbooks, certification review guides, clinical references, and exam preparation resources that can support you from nursing school through specialty certification and beyond.