What overwhelms you the most? What did NS NOT prepare you for?

  1. 11
    Hi new grads!! I am trying to gather some real life information to bring back to my clinical students. I don't want this to be a bashing thread about your instructors (because it's never OUR fault...ha ha ha ), but rather a reflective thing.

    The reason I pose this question is this: My students (as many others before them) think that nursing school (and nursing thereafter) is all about skills!! If I had a dollar for every student that has complained that they have not inserted a foley, or are nervous about it, I'd be a millionaire!! Our graduating class did a survey (for a research project) and the most popular answer for "what skill do you feel most unprepared for as a new nurse" was that!! This beat 'taking care of a vent patient' :uhoh21:. Meanwhile my students (while very good this semester... 2nd semster) still at times could not give me a nursing diagnosis, tell me why patients were on a baby aspirin (pain?), where the MD orders are in the chart (or why we need to check MD orders to the MAR, not MAR to their cheat sheets) or other "non-tangible" skills.

    I know skills are important. But as time goes on, you get these skills. I tell them a monkey can insert a foley and set up an IV. I also told them that I would never fail someone who did not perform a skill correctly (ie break sterility during a foley). Maybe it's just me, but the other things are more important, like how to assess, problem solve, prioritize, communicate, and most of all apply the theoretical knowledge into clinical practice. I tell them there is a reason they sit there in lecture.

    So basically, I wanted to know: has anyone ever been thrown off orientation because they didn't remember how to perform a basic skill, or made a mistake with it? What gets you caught up as a new grad? And what can I tell my students (I have a feeling that nothing I say will help )?
    Last edit by ProfRN4 on May 2, '08
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  3. 76 Comments so far...

  4. 7
    I agree with you one hundred percent. Skills come eventually.
    By far, the greatest Issue I had as a new grad and at my last jobwas lack of support. Entered a job in LTC and lacked some basic skills, even though I had been working in a community hospital for a year already. I was overwhelmed with anxiety when my preceptor became "annoyed" any time I wasnt proficient at a skill. In turn, I performed worse. Granted, in hind sight, I wish I could have been less sensitive. But STILL,to be in a new job, you need support.

    I wish Nursing school prepared me to be tougher on the inside. And it did, to a degree. I think to be a successful nurse you really have to have a thick skin, not freak every time someone isnt that nice. But how do you teach that?

    I also think people in the experienced world have a responsibility to the less experienced nurses. They need to act a s resources and help rather than put other nurses down.

    Ultimately, nursing school certainly gave me the foundation to think critically in situations. I am working and supporting myself and my son, so I
    consider myself successful.I also passed nclex on the first try.
    You must be a good teacher, because your perception of whats important is right on, IMO.
    Lisa
  5. 5
    These nursing students are not in the first semester anymore. They should already progress beyond that. When I was in nursing school, you were expected to know basic nursing skills the first semester. It's not all about skills... Critical thinking! understanding the diease process and putting two and two together. What would they do if the patient starts to deteriorate? I think they need to understand and review the scope of pratice and the nursing practice act.
    As a new grad, I struggled with communication with doctor. In nursing school I did not call or speak with the doctor about my patients. Now as a new grad, I am making all these calls. Communication is important! We are always implementing, but evaluation of the nursing process is not always done. I admitt in nursing school, I never checked the orders. Now, I am constantly checking and updating the MARs and orders. Another thing with orders, it always important to verify the past orders about a medication prior to administration.... double checking the correct doseage or making sure it still needs to be given. It's ok to learn from a mistake, but what about possible mistakes with Patient safety? Documentation... for communication. but most important the possibility of going to court. Delegating the basic tasks to the UAP will help prioritize.

    hopefully that will help
    oncnursemsn, Devil_Duckie, MMARN, and 2 others like this.
  6. 8
    Hi,
    I'm just finishing up my orientation and here are the biggies that stick in my head...also, I apologize in advance for any typos and bad grammar as I haven't yet had my morning tea:wink2:zzzzz


    I agree that it is not all about skills. My hospital reviewed skills in orientation. Critical thinking is the big thing. How to assess your patient and know what you should be on the lookout for with specific diagnosis. How to tell if pt is starting to go downhill.

    Dealing with pt's and family members is another issue that wasn't covered in school. How do you deal with that needy pt and demanding family while still carrying a full load of 4-5 pt's.

    Lastly, we really didn't cover Dr's calls....What situations warrant a call (besides the obvious; emergencies, critical lab values etc) and what situations just require that a note left on the chart. Imagine my surprise when during my first Dr call the Dr asked me "what do you think I should do?" when I reported that a pt's antibiotics wasn't compatible with her tpn.....He wasn't being sarcastic, he really wanted my input. I have found that most Dr's rely on us to make recommendations because we see the pt so much more than they do. We also can't just assume because the Dr gives an order for accuchecks that he will remember to right an order for coverage, etc..we have to be thinking 5 steps ahead at all time.....
  7. 9
    Great thread and thanks so much for thinking of your students and thier concerns.

    I graduated in Dec 07 so nursing school is FRESH in my mind. Let me tell you the hardest part I had in acclimating into the nursing world. It was not the technical part per say, as that comes with practice and on the job training. I found my hardest part to be report. That may sound silly, but getting a good report is so important. "Just the facts maam" is what a good mentor nurse told me. Maybe you could encorporate into your post conference having each student give approx a 2min report on each of your students patients that day.

    Also getting over the nerves of calling a Dr. Have your students practice on each other of calling a Dr for a problem, once again "just the facts maam"
  8. 8
    Have you seen the thread entitled "Hospital Orientation SUCKS?" There's a lot of discussion there about the perceived shortcomings of both hospital orientation and nursing school.

    I'm not really sure how to answer your question. Truthfully, I think both my nursing school education and my training in orientation were about as good as possible, given the time available. I hated careplanning with a passion, but I think I probably learned more from it than anyone in my class--in part because I had more to learn. I have described my clinical experiences as an hour of pre-conference, three hours with a patient, an hour of post-conference, and fifteen hours of writing about it. I don't really feel that prepared me for handling a patient load. But, on the other hand, my previous job had elements of patient care, mostly transfering to and from bed, plus sometimes helping the aides and nurses with turning/moving difficult (very large and/or ortho) patients for baths, dressing changes. I blew off a chance in clinicals to observe an LP, because in my work I was the world's smartest restraint device and had often assisted in positioning for LPs. Still, I was amazed how nervous I was, dealing with patients in clinicals. Dry mouth, sweaty palms, queasy stomach even when all we were doing was ADLs and assessment. So I think the time I spent with them was valuable, even though I went through some of it all over again as a new nurse.

    As far as which skills I wish I'd seen more of in school, well IV starts, of course. I started two in NS, and they were fairly easy with a nurse guiding my every step. Nothing like labs, but I was relieved to find it was something I was going to be good at. Or so I thought. As a working nurse, IV starts have been a bear! But I have a theory that you have to miss a hundred IVs to get good at it. You miss the first thirty in your first month. By six months, you've missed forty more. Going on three years, I'm still working on the last thirty, and some I've missed are ones nobody can get. Obviously, there isn't time in school to attempt that many IVs--and I have known a few who were good from the first try.
    Female urinary catheters have also been a bit of a bugaboo. Males are easy. My first couple of NGs gave me trouble, but after that I've found them not too bad. I was lucky to have a patient with absolutely no gag reflex who pulled hers out a couple of times.
    I think a bit more time with dressing changes could have been helpful in school. At my facility, all of the daily dressing changes are done on nights, so it would have been nice to have been quicker and more organized with them. Hasn't been a huge problem, though--the hardest part is having everything ready before you start, and your feet teach that to your brain.

    I guess my biggest problem with clinicals, now that I think about it, was that it didn't really feel like a chance to practice and learn. It felt like an exam. My instructors (properly) emphasized the need to be well prepared and practice safely, but it felt like each task was a return demonstration to prove I knew how to do whatever skill was involved. Some of my "rotations," apart from the clinical group and under the supervision of a staff nurse, rather than an instructor, were far less intimidating. The staff nurses, and many of the nurses I oriented with, began with the assumption that I didn't know anything--which was close enough to true! Luckily, I've been under the mentorship, both in those rotations and at work, with nurses who seem to really enjoy passing on what they've learned, so it has been hard, but not horrible.

    I agree that critical thinking is important. It also has the advantage of being something you can learn a lot about in a classroom or a lab. I don't buy for a moment the idea that the manual skills are something a monkey could learn. When I was learning carpentry, my father said the first thing you have to learn is how to drive a nail. It's basic, but it's a skill that has to be learned. The lessons of driving a nail--don't force it, let the tool work for you, not against you, pay attention to what you are doing--aren't nearly as obvious as they sound, and they apply to pretty much every other skill you'll ever learn.

    I've joked that in clinicals, we had to learn the name, the purpose, the side-effects, the possible adverse reactions of every pill we gave, but no one ever shows you how to get it out of the bleeping package.
    GApsychNurse, RoyalNurse, palee, and 5 others like this.
  9. 12
    I was a nurse manager. During my career as a manger, we terminated several new grads. I say "we" because the decision to fire is never made by a single person. It was a group decision that included the manager, director of nursing, nurse recruiter, nurse educator and director of personnel. New grads were terminated for the following reasons when patient safety became an issue:
    • a compilation of the same errors (more than one type) being made over and over (i.e., the person isn't learning from their mistakes)
    • drawing up insulin in a 3cc syringe with a 1 and 1/2 inch needle and attempting to administer it to a patient IM
    • falsification of medical records (recording fingerstick blood glucoses in patient charts that had never been done)
    • administering oral Morphine Elixir intravenously after several nurses told the person to call the pharmacy first to ask how the "blue Morphine solution" was to be given
    • consistently hanging the wrong IV solutions on the wrong patients
    • tardiness and absenteeism
    • failing the NCLEX
    This doesn't reflect the ones who we discovered had a negative attitude or difficulty getting along with other staff members after they were interviewed and hired. We got them out the door through continued pressure applied in verbal or written counselings. We were not willing to tolerate behavioral problems.

    We were very well aware that new grads hadn't had any experience at doing most of the nursing procedures at their time of hire. Our orientation program was designed to give them those experiences and the preceptors main job was to help them learn to organize and prioritize the tasks they needed to get done. We tried very hard to extend a lot of learning time and patience. Problem solving on the job and fitting that in with daily routines is probably THE biggest challenge facing new grads once they get over this anxiety about the hands on procedures. What many don't reralize is that depending on the unit you work on, the type of nursing procedures you will be doing will vary. It will take them months to years to master the practical and clinical application of problem solving (the nursing process).

    Personally, the two big procedure hurdles for me were starting IVs and managing chest tubes (I worked on a stepdown unit at the time). It took me a long time to master the art of starting an IV.

    One of the reasons I focus so much on the students following the steps of the nursing process when they are writing their care plans for school is because it is helping to get them to learn to think critically by pulling a lot of information together and prepare for the problem solving they are going to need to be doing as RNs on the job. The RNs primary job is problem solving and patient care management. If it were all about the skills, they wouldn't be letting LPNs pass medications, insert foley catheters, do trach care, sterile dressing changes and start IVs. And now, in some states they have turfed off the medication administration to unlicensed medication aides. Your analogy that a monkey can insert a foley is correct. Was George Lucas predicting a future in Star Wars Episode III when he showed a robot midwife assisting in the delivery of Padme's twins? As long as costs rise, third party payers dominate payment schemes and a nursing shortage persists, nurses will be valued for their thinking and decision making ability and patient care management knowledge and not for what they can do with their fingers and hands.
  10. 8
    Quote from Daytonite
    I was a nurse manager. During my career as a manger, we terminated several new grads. I say "we" because the decision to fire is never made by a single person. It was a group decision that included the manager, director of nursing, nurse recruiter, nurse educator and director of personnel. New grads were terminated for the following reasons when patient safety became an issue:
    • a compilation of the same errors (more than one type) being made over and over (i.e., the person isn't learning from their mistakes)
    • drawing up insulin in a 3cc syringe with a 1 and 1/2 inch needle and attempting to administer it to a patient IM
    • falsification of medical records (recording fingerstick blood glucoses in patient charts that had never been done)
    • administering oral Morphine Elixir intravenously after several nurses told the person to call the pharmacy first to ask how the "blue Morphine solution" was to be given
    • consistently hanging the wrong IV solutions on the wrong patients
    • tardiness and absenteeism
    • failing the NCLEX
    This doesn't reflect the ones who we discovered had a negative attitude or difficulty getting along with other staff members after they were interviewed and hired. We got them out the door through continued pressure applied in verbal or written counselings. We were not willing to tolerate behavioral problems.

    We were very well aware that new grads hadn't had any experience at doing most of the nursing procedures at their time of hire. Our orientation program was designed to give them those experiences and the preceptors main job was to help them learn to organize and prioritize the tasks they needed to get done. We tried very hard to extend a lot of learning time and patience. Problem solving on the job and fitting that in with daily routines is probably THE biggest challenge facing new grads once they get over this anxiety about the hands on procedures. What many don't reralize is that depending on the unit you work on, the type of nursing procedures you will be doing will vary. It will take them months to years to master the practical and clinical application of problem solving (the nursing process).

    Personally, the two big procedure hurdles for me were starting IVs and managing chest tubes (I worked on a stepdown unit at the time). It took me a long time to master the art of starting an IV.

    One of the reasons I focus so much on the students following the steps of the nursing process when they are writing their care plans for school is because it is helping to get them to learn to think critically by pulling a lot of information together and prepare for the problem solving they are going to need to be doing as RNs on the job. The RNs primary job is problem solving and patient care management. If it were all about the skills, they wouldn't be letting LPNs pass medications, insert foley catheters, do trach care, sterile dressing changes and start IVs. And now, in some states they have turfed off the medication administration to unlicensed medication aides. Your analogy that a monkey can insert a foley is correct. Was George Lucas predicting a future in Star Wars Episode III when he showed a robot midwife assisting in the delivery of Padme's twins? As long as costs rise, third party payers dominate payment schemes and a nursing shortage persists, nurses will be valued for their thinking and decision making ability and patient care management knowledge and not for what they can do with their fingers and hands.
    I think this about covers it. Everything learned in nursing school HELPS in the real world, but it truly is NOT enough preparation -- and I believe it's not possible to cover everything in nursing school, nor is it realistic for ANYONE to expect this.

    My employer (manager, charge nurses, and accepting co-workers) have made it clear to me that patient SAFETY (i.e., NOT making the mistakes listed above) is by far the most important thing. If I miss an order or med, yes, it will upset the night shift, but -- if the patient is not harmed by this omission -- then it is nothing more than an omission.

    At the end of the day, I ALWAYS go back to SAFETY. I review in my head if my patients were safe all day. Did I do (or not do) something that compromised their safety? For example, I've had a couple patient falls that I, despite all my explaining and checking on the patient FIVE minutes before the fall, could not prevent the fall. Once the patient has fallen, though, did I do everything I should have to follow up (i.e., notify my charge, call the doc, and file a report?) and ensure the patient is safe AFTER the fact? If so, then, despite the fall, the patient is still "safe."

    Skills come with time. I am learning new skills every day.

    Critical thinking is truly important. If I don't know anything about X medication, am I going to give it -- or am I going to call pharmacy and ask about it, look it up in my drug guide, and give the patient/family info on it?

    Am I going to keep making the same mistakes? I sure as heck hope not, or there is certainly something wrong! (Is this a lack of critical thinking, laziness, or perhaps some minor stupidity?...)

    I'm thankful that our medication system is entirely electronic. For example, one day, I had 2 patients that required a Mg rider. Sure, they're both getting the same med, but it's not going to look so good if pt X has pt Y's bag hanging next to them... Thankfully, the SYSTEM helped me catch me error. Other than that, although my system helps me perform the 5 rights, I still make sure to do them on my own (with few exceptions -- such as the Mg rider example).

    Ultimately, if I don't know how to do a skill, I ask for help. Because, as I said, it's impossible for me to have learned all of that in nursing school -- even in clinicals. There are 20 year veterans who are still learning -- and I believe EVERY nurse should be learning throughout her/his ENTIRE career.

    I remember thinking that the care plans we did in nursing school were a joke because they are NOT used in the hospitals -- at least not in the same form that we used them. They're much less formal. Much of it is actually not written so much as it is applied in practice. Our computer system generates the care plan for us, actually. And, again, it's not nearly as formal as it was in nursing school. One thing that helped me tie these care plans back to real world nursing occurred recently when my charge told us that, to prep for the JC coming soon, we should be writing daily goals for our patient's on the dry erase boards in their rooms. At first, I thought this was a lame attempt to appease the JC. So, on my next day of work, I brought in my care plan book to help jog my memory into writing formal goals. I realized other nurses were writing less formal (and more realistic goals) -- i.e., "controlled pain" vs "optimal cardiac output AEB ..." -- which I quite liked. It helped bring all my learning full circle.

    I know that was a bit circuitous and "ranty," but (in reality) that's how nursing is! One of my unit secretary's referred to it as "uncontrolled chaos" -- something I've NEVER heard before. It freaked me out before (because I'm SO anal!)... but it's SO true!

    As long as my patients are SAFE at the end of the day, I know I've done my job well. Also, yeah, it's pretty important to get to work on time and make sure to do all my work on time
    pinksunRN, GApsychNurse, RoyalNurse, and 5 others like this.
  11. 10
    While skills aren't the end all be all of nursing, they ARE a key function. A nurse will never be great at all skills because there are too many out there. But an experienced nurse has the confidence that they CAN learn more skills because they have ALREADY mastered some. If nursing school only introduces students to skills but never gives an opportunity to master any, then the student/new grad never has the chance to build confidence in their ability to learn and master new skills. They don't have a clear idea of their own unique way of learning such skills or gauging how long it will take them to feel comfortable with it.

    Also, when students don't have the change to master a good number of basic skills, it slows them down considerably in regard to all of the other nursing responsibilities they are responsible for as new grads. When it takes 10 minutes to hang an IV instead of 2 minutes, 20 minutes to prep and insert a foley instead of 5, in addition to the newbie needing extra time and assistance in figuring out what to do, to prioritize, other staff quickly get frustrated that the newbie is SOOOOO SLOW.

    New grads DO get hassled by experienced staff for not being quick at basic skills. "What DID they teach you in school?" "My school wouldn't let you graduate without knowing THAT" eyes rolling, sighs of exasperation etc.

    It's one thing if a nurse needs to learn one or two new skills along the way. But many newbies don't have much of anything down that well, so just - about - every - step - is - interrupted - by the new grad needing assistance, guidance, instruction. And while some facilities are offering longer, more comprehensive new grad programs, many places want the newbie on their own and taking their own load within 8-12 weeks.

    And so much info is crammed into nursing school, there's no way to master it all. Much of the stuff you'll be familiar with but not able to quickly remember. So there you are, a new RN, and feeling like you have nothing to offer your colleagues. You can't insert an IV or foley, etc, you don't know what meds and treatments to expect off-hand (will have to look them up til you're familiar with them from having worked with them day in and out); you can't recognize if an order is a little off; you don't feel capable to help out in an emergency (can't do much besides push the code blue button); you're not confident of your ability to judge when a patient is going bad (and will be wanting to test your judgement against experienced colleages and may well be wrong many times - huff, you bothered me for THAT?! or How could let it get THIS bad?!)

    So having mastered some skills DOES impart a degree of confidence that can be built upon.

    And, my instructors were VERY nitpicky in how procedures were performed. You'd think you might accidentally kill a patient if you didn't hold the cotton swab just so. Ugh!

    Another thought is that mastering a skill is a clear objective. Much of nursing education has rather vague objectives. The text has too much material to master (1000 pages/subject!!). Critical thinking is something you learn by doing and reflecting... you can't just check critical thinking off your list of things to learn. Meanwhile, students DO have a list of dozens of skills to check of, presumably indicating that they *KNOW* how to do it, not just that they've seen it once, done it once.

    Meanwhile, they'd TELL us to use our judgement and our critical thinking, but based on what PRACTICE??!! Based on what knoweldge? Based on what EXPERIENCE??!!

    Nursing DOESN'T teach much depth and many nurses know what to do because it works... and then they have some idea of why it works, but often not the complete picture. I might have a wrong judgement, but the rationale as to WHY my judgement was wrong often didn't make sense (eg trying to explain why holding the cotton swab a certain way was considered bad practice). Often, one's thinking process was not considered at all (eg you're off but the thinking process was good)... only that the 'correct' conclusion was given along with a good rationale (though the person just may be parroting and not really understand).
    Last edit by jjjoy on May 2, '08
  12. 1
    Thank you so much for this thread and the contributions thus far. I am graduating in less than 2 weeks and am positively freaked out that soon (if I pass the NCLEX, of course) I will be getting a license to practice nursing. I am excited to graduate, for certain, but I feel like such a poser right now. My grades have been good, I'm told my skills are fine, but going through preceptor has shown me all the things I don't know yet (I've never had the opportunity to work with chest tubes or trachs; very little experience with NGs) and everything I do seems to take so much time. I want so much to go into a new job feeling confident, but I see that this will be next to impossible.

    I guess now that I'm at the end, I see that my first job will probably entail a lot of "on-the-job" training..... like nursing school was just the prep work. I did not think it would be like this. But it sounds like from reading what others have written, this is just the reality of nursing.
    GApsychNurse likes this.


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