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