[nursemike]

Originally Posted by lareine23

As I read this thread I can't help but to feel a little apprehensive about entering my new grad position on a telemetry unit. I want to know, how can I prepare myself to meet my preceptors half way and make the best out of my experience. I want to be a great nurse and if it means tapping into outside resources that will provide the training that I may not get either in school or during orientation.... I WILL DO IT, because ultimately someone's life is in our hands and I want to save lives.

Please bear in mind that people aren't as apt to post when their orientation was great, so you're apt to get a skewed view. You'll see an occasional "I love my preceptor!" thread, but like everything else, people tend to vent more than bubble. For the record, my orientation was great, although I did wonder if it might have to be extended until everyone got a chance to precept me. I worked on my unit before school, so I wasn't among strangers. But I worked a slightly odd schedule (nights/weekends) so I precepted with whoever was available. One night, our charge had to take a full patient load, so she took the easiest assignment on the floor and me as an orientee. So I basically did the assignment and she checked on me from time to time. It went very well, and I got to feel like I was actually contributing to the unit, which was refreshing.

If I had it to do over, instead of orienting with whoever was available on my schedule, I think I'd have asked to work 40hr weeks on dayshift. It seems to me that starting the shift and ending the shift are the hard parts--like flying a plane. If you can take off and land, the middle part is just cruising, unless something bad happens. And I agree with what appears to be the prevailing view, that continuity with a preceptor is important. Then again, as one CN observed, the first time (of many) I got a third different assignment on the third consecutive night, "Flexibility is the name of the game." (It's nice to get the same patients, night after night, but it doesn't always happen.).

The other thing to realize is that orientation is hard, in much the same way school is hard, because it has to be. You have a lot to learn in a short time. In fact, the whole first year is hard, and the second is no picnic. I love my stupid job, but there are two sayings I repeat to myself on a fairly regular basis: "I used to say my only problem was not having anything to complain about, but now I'm a nurse and my life is perfect"; and "If they wanted a good nurse, they should have hired one."

Work hard. Keep a sense of humor. Be confident. Be humble. Bear in mind that if you can survive this, truck driving school is going to be a piece of cake.

[llg]

It hasn't been my intent to turn this into a "which is better, ADN, Diploma, BSN, or MSN entry" thread. In fact on of the worst programs in my region is a BSN program.

There are good quality programs -- and poor quality programs -- at every level of education.

My point is that some programs (at all levels) have turned into "factories" that produce people eligible to take NCLEX but who have not learned much about how to actually BE a nurse and DO nursing. That seems to be a fairly common response to the nursing shortage -- to create quick "short-cut" programs to get more RN's quickly and to provide "new, creative options" for students that may or may not provide the strong foundation needed for success in the field -- but they bring in money for the schools and produce large numbers of newly licensed RN's that make people look good.

Unfortunately, the new grads coming from some of these programs are unprepared for the real world of professional practice. They struggle with their role transition and create all sorts of problems in the practice arena. Many of them end up leaving their jobs -- blaming their fellow nurses and/or their employers when the real source of the problem is their lack of proper preparation.

Of course that's not the problem with every new grad who struggles ... but I am seeing it more and more ... and the profession needs to acknowledge it instead of pumping more resources into the creation of more sub-standard nursing education programs.

[nursemike]

Originally Posted by jjjoy

I appreciate hearing from someone who actually has experience with another profession, and even the one I happened to choose as an example!

I've thought for awhile that a trade model (apprentice/journeyman/master) makes more sense for nursing than a professional model. Carpentry is a science--proper joinery (even with nails) and structural integrity, but it's also an art (aesthetics). Sound familiar?

Originally Posted by jjjoy

In school, they kept saying how we'd need to be leaders and to be responsible for the work done by those we delegate to and to recognize questionable MD orders and to stand up for proper care... yet meanwhile, we barely learned the practical WHAT that we were to be leaders of and taking responsibility for and delegating. Without experience, only the most egregious of orders would be noticeable to a newbie, and who allows newbies time to look up every new order to check if it's okay? Finally, proper care? Isn't that a detailed 5 page care plan? No?

I remember paging a resident, early on, with some (not too major) problem and getting, "What do we usually do for that?" Eek! (I'm secure enough in my manhood to occassionally say "Eek!") It's times like that you really appreciate mentors who continue to mentor even after orientation is officially done.
And don't get me started on delegation...a first-year RN delegating to a 10+ year LPN...well, it ain't like we learned in school. Luckily, I learned enough through life experience to know when to shut up and do what I'm told. Where I did most of my clinicals, they have "team nursing," where an RN, LPN, and aide share an assignment. Never had time to watch how that went, though, and I still don't fully understand the LPN I and LPN II business. At my facility, the LPN (if there is one) has her own assignment and an RN assigned to "cover" her. Usually, each RN covers a couple of patients, so the LPN might interact with 3 RNs. It's kind of messy, in a way, and I'm not 100% sure it's entirely legal, but once you get to the point where you do know "what we usually do for that," it gets to be more of a collaborative relationship, and it works.

One thing I've noticed is that LPN programs, around here, are one year of nursing school. My ASN was two years, but nearly half my courses had little if anything to do with nursing. I really enjoyed American Government.
The instructor was great, and the class was facinating, but it doesn't help a bit when I patient is going south. I guess I do have an insight into what to expect when the family sues my pants off, but I'd much rather know how to operate an ambu bag. So, really, graduate PNs have at least as much "practical" nursing as I did as a GN, and, at least starting out, the major extent of my "critical thinking" was to keep calling until I found someone who knows "what we usually do for that."

Originally Posted by jjoy

Nursing education used to be a lot more clinical intensive. Students would live at student dorms adjacent to the hospital and work several shifts... they got to learn and become licensed while hospitals got cheap help. By the time they graduated, they were supervising the lower level students and practially running the floor themselves. So, they were actually experienced with full nursing responsibilities by the time they graduated.

Now that's going way back and I don't know how many of those grouchy, grumpy nurses actually had THAT kind of training. But it seems that over time, the clinical portion of school has changed from turning out proficiency to giving an introduction.

I only know one Diploma nurse, and she has decades of experience, so it's hard to say how much of her skill comes from school and how much from OJT. What I do know, of her and our other very experienced nurses, is that they seem happy to teach anyone willing to learn, but they also expect you to start to stand on your own feet in a reasonable time. Which is pretty much exactly how I felt, training a new guy on a carpentry crew. It's worth the effort to gain a co-worker who'll be able to share the load, but if they aren't paying attention, who needs them?

[cjmjvr]

Right on!!!!!!!!

[VickyRN]

We are having a very difficult time in our college of nursing finding suitable clinical sites (especially in the specialty areas such as PEDS) for all our students. It is a challenge. The one quality pediatric unit in our area is overloaded with students.

[llg]

Originally Posted by VickyRN

We are having a very difficult time in our college of nursing finding suitable clinical sites (especially in the specialty areas such as PEDS) for all our students. It is a challenge. The one quality pediatric unit in our area is overloaded with students.

That's a major problem in my area, too. But a big source of that problem is the proliferation (and expansion) of programs that are of poor quality. They take up valuable clinical slots that could be used by the better programs. All those students in poor quality programs are making it more difficult for the high quality programs to get the slots they need.

I truly believe that we would produce more and better nurses (who would be successful in practice) if we would focus our attention and our resources on the better programs -- or at least only on the students with a little interest in those specialties. The region would produce a slightly lower number of new grads ... but the new grads produced would be well prepared to succeed and be more likely to stay in the profession. We can't afford to go on wasting the scarce resources.

I"d guess less than half of the students who come to my hospital for clinical rotations have a reasonable chance of being hired by us as new grads. The quality of the education provided by their schools is simply too weak. .... And yet, because of politics, we must give them access to our hospital to use as a clinical site.

[elkpark]

Originally Posted by llg

That's a major problem in my area, too. But a big source of that problem is the proliferation (and expansion) of programs that are of poor quality. They take up valuable clinical slots that could be used by the better programs. All those students in poor quality programs are making it more difficult for the high quality programs to get the slots they need.

I truly believe that we would produce more and better nurses (who would be successful in practice) if we would focus our attention and our resources on the better programs -- or at least only on the students with a little interest in those specialties. The region would produce a slightly lower number of new grads ... but the new grads produced would be well prepared to succeed and be more likely to stay in the profession. We can't afford to go on wasting the scarce resources.

I"d guess less than half of the students who come to my hospital for clinical rotations have a reasonable chance of being hired by us as new grads. The quality of the education provided by their schools is simply too weak. .... And yet, because of politics, we must give them access to our hospital to use as a clinical site.

As usual , I completely agree.

[SoundofMusic]

LLg, what do you mean by poor quality programs? How would you describe them?

I'm surprised that any nursing program would be described as "poor" - aren't there standards they all have to meet?

IMO, and it's only that, I believe in nursing school we could add on a class called "Basic Nursing." Here is where you'd learn all the itsy bitsy stuff that would be like the oil to your practice -- you'd learn how to operate wheelchairs, where things are located, how to operate machines, what to do about all the simple problems ... or, we could follow techs around for a few weeks. Because the drills we have to do during our clinicals do NOT focus on the small stuff. You're gearing up to do concept maps -- lots of that is done from the books and combing through a patient's chart, and a bit of assessment. However, you're still not learning how to make that patient comfortable, answer the million questions they have all day, etc -- all the stuff you really DO as a nurse, besides assess and manage their care.

Here's one example. I had a pt. the other day who was livid because he had to wait for his MRI so long. MRI even called me to say they were coming, only to cancel. Later I learned our gigantic hospital has only 2 machines, that ER gets them first, then oncology, etc, etc. Well, that small bit of info would have helped me out a lot to explain to him .. but I didn't learn it until later. I dont know -- I guess it's just knowing those small ins and outs that help so much. I'm not sure if a class would even help ...you just have to bug your preceptor/mentors to find out that info.

I feel many of the theory and patho type classes need to concentrate more on real life "case" situations -- lots more application and learning how to think critically and tie loose ends together. I remember doing about TWO cases studies in many of those classes --yet all day long as work each patient is basically a case study in themselves. We just need more emphasis on #1 -- survival and #2 -- critical thinking.

[llg]

Originally Posted by SoundofMusic

LLg, what do you mean by poor quality programs? How would you describe them?

I'm surprised that any nursing program would be described as "poor" - aren't there standards they all have to meet?
.

Standared don't solve problems. They are simply statements of intent -- not concrete solutions to real life problems. You have to remember that standards are written, interpreted, implemented, monitored, and evaluated by people -- people who can water them down in the name of expediency and practicality. That is the nature of a standard.

For example, a school will schedule their students for clinical on a unit -- but they spend most of their time on the unit hanging around just observing because: (1) Their instructor is not competent to supervise them doing much care. (2) They are only going to be on that unit for 2 or 3 days, so they never get sufficiently oriented there to function. (3) They come to clinical not having researched their patients and spend most of their time reading about the patient and learning about their needs -- rather than actually fulfilling those needs. And yet, on all the paperwork that goes to the BON and the accrediting agencies, the students had several hours of "clinical" that day. It's no big deal if that happens occasionally ... but when most of the clinical days are of the this nature, the student doesn't learn what they need to learn -- and yet the paperwork shows an adequate number of clinical hours to meet the standard.

Back in the old days, "clinical" meant showing up with a care plan already semi-done. You had to go into the hospital the night before to get your assignment and then spend 3-5 hours researching the disease, meds, tests, etc. so that you would arrive for your clinical ready to meet the patient's needs -- not to learn about your patient and what those needs might be. The principle was that you could not properly interact with the patient unless you had first done your homework and had a formulated plan of care. So, the clinical hours were used to practice and learn the "how" of the minute-by-minute delivery of nursing care. Homework and classes were used to teach the "what" and "why." Students graduated knowing "how" as well as "what" and "why" because "how" was the focus of most of their clinical hours.

I see much less emphasis on the "how" in clinicals today. The "what" and "why" have not been adequately covered beforehand and they are using clinical hours for that so that they can pass the NCLEX. As for how to actually deliver the care, that's something you are supposed to learn in orientation as a new grad -- but the schools did not ask the hospitals if they have the resources to take over that aspect of nursing education. Nor did they ask the patients and insurance companies who are now being asked to pay for all that orientation. (And no, I am not against good orientation programs. I just wished we had all discussed it before the schools decided on their own to stop teaching a lot of the "how" of nursing.)

Also, students used to have clinicals at least 2 or 3 days per week. Even if the total number of hours was only say, 15, it was still on 3 separate days. That gave the student 3 times to have to practice an overall assessment, AM care, lab tests, dressing changes, procedures, etc. In some cases today, the student may only have 1 shift per week in the hospital. Even if it's a 12-hour shift, there is less learning because the student only has to fully assess the patient once, do AM care once, change the dressing once, help with only 1 day's procedures, etc. Again, the hours spent "in clinical" may be the same, but the learning is decreased.

I think your suggestion about adding more content on the "little things" (but important things) to nursing programs. That's one possible approach to the problems I have been ranting and raving about in this thread. But your solution would require nursing programs to be a little longer to include that content ... and many of today's new programs are trying to reduce the time it takes to become an RN. ("Get your RN in only 12 months! Only $25,000!" "Hurry, hurry, you too can be a respected professional with job security with just a 15 month weekend program!" "Don't have time to be a full time college student? No problem! Just pay $30,000 and you can be an RN in only a year while still working a full time job!" etc. etc. )

There is simply too much necessary content for programs to be shortened significantly -- unless it is a total immersion program in which the student considers school to be his/her full time job and has minimal outside distractions. That's not always the way it happens.

Other programs fulfill the standards on paper, but don't have quality clinicals and/or classes. And as I said in an earlier post, it's politically difficult to close down or discipline a program unless it can be proven that they have done something so scandalous or blatantly wrong that the public (and alumni) would support it.

So, yes, there are lots of bad programs out there -- pumping out thousands of new grads each year who are not prepared to be a nurse in the real world.

[*ac*]

"Back in the old days, "clinical" meant showing up with a care plan already semi-done. You had to go into the hospital the night before to get your assignment and then spend 3-5 hours researching the disease, meds, tests, etc. so that you would arrive for your clinical ready to meet the patient's needs -- not to learn about your patient and what those needs might be."

As a recent grad, I don't disagree that clinicals are inadequate, but just wanted to tell you the rationale for discontinuing the practice of going in the night before to get chart data: Stays are so short for pts these days, that often students would do this and then the pt would be discharged by the time they came in or shortly afterwards. On the unit where I work now, I've seen clinical instructors come in the evening to look over our patient load and have trouble coming up with an adequate assignment list for her students of patients who would definitely be there the better part of the following day.