[*ac*]

"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 wholeheartedly agree with this. It's a RARE clinical instructor that keeps students the entire 12-hour shift - there just isn't enough to do that the students are allowed to do. Multiple shorter days would be much, much better.

[SoundofMusic]

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 have a friend whose program does do this -- she said it was tough, but obviously, this truly IS the way to go to really do the "thing" that a nurse does. All we did was pick ONE patient about half way through (during clinicals that only lasted until noon about twice a week), and do ONE concept map on that patient. There was no way to do anything but follow a nurse everyday, and knowing absolutely nothing about WHY she was doing anything with that particular patient.

And by these "standards" my own 2nd degree program from a reputable nursing school falls woefully short. We were only truly observing -- not gathering the info needed to really interact like a nurse needs to do.

A lot of lights have come on for me through this thread ... now at least I know why I'm struggling and can stop being so hard on myself.

So, It's not ME -- it's the culmination of an education that falls short of what I really needed. Nothing I can do about it now except to do the best I can to learn the small stuff and move on.

[elkpark]

Originally Posted by SoundofMusic

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.

In addition to, again, agreeing completely with everything llg said, I would also add that all nursing schools used to have (and most still do, to some extent) courses like you describe. However, as we've gotten more and more "hoity-toity" in nursing education, there is less and less focus on "hands-on" nursing (esp. in the accelerated BSN and direct-entry MSN programs ...). I'm just speculating here, but I would imagine that if you went back and made that same statement to the faculty in your nursing program (you said earlier that you went through an accelerated program, right?), the response of most or all of the faculty would be that that kind of stuff (actually knowing how stuff works and taking care of clients' basic comfort and needs) is not what you're there to learn, not what the RN needs to know, it's a waste of your intelligence and education, etc., etc., etc. Something had to be dropped to produce all these abbreviated nursing programs, right?, and the basics are what has been dropped from many programs -- the rationale being that you can always pick up that stuff on your own later on; it's the higher level stuff that is really important to teach (of course, part of the problem is that the nursing faculty aren't interested in teaching the basics of nursing care, it's more engaging and satisfying for them to teach the "higher level" stuff -- hey, they didn't get all those advanced degrees in order to teach people how to perform basic skills and care!) IMHO, though, that leaves you with a "house" constructed without a foundation. Too many students graduate from (many, not all) RN programs and get licensed as RNs, but have no idea what nurses do to get through a shift on a nursing in a hospital (or anywhere else), or how to think about and provide for people's basic needs (despite all those careplans, OPTs, concept maps, etc ...) Ironically, the expectations in the real world are exactly the opposite -- (your) employers and co-workers don't care how lovely an OPT or concept map you can write; they just want you to be able to get through the shift safely and competently (at, at least, a basic level).

Again, it's v. "politically incorrect" to say in nursing circles (esp. in nursing academia!), but, IMHO (I know, lots of people disagree with me), we used to do a much, much better job in this country of educating nurses, and the "improvements" we've made in the last few decades are not really improvements. While the amount of knowledge necessary to practice safely, and the accountability/liabilty nurses bear, have increased steadily over the years, students, in general, now graduate knowing much less about how to be a nurse, what nurses need to know to do their jobs, than they used to and yet with a variety of v. unrealistic expectations of what they are going to find when they enter the "real world" of nursing -- and you can see the unfortunate results of this phenomenon on this board all the time ... Those of us who have been around for a while are aware of how much nursing education has been watered down in recent decades, and I think we're getting close to finally reaching some kind of breaking point.

[SoundofMusic]

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.

This is so IT!!!!

We read about the needs, but never learned how to really fulfill them, critically think about WHY, HOW, and in what ORDER we would fulfill them. We were just mere observers.

I hate to say it, but I think what's happened to healthcare has just spread to the schools -- all in the name of more money and expediency.

[llg]

Originally Posted by *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.

Yes. It's a problem. But turning clinicals into minimally useful observations is not the answer.

Schools are using such problems as excuses for not maintaining higher standards. By late afternoon, most patients who might be discharged that night can be identified). And if the patient DOES go home the next morning, the student can still get a good experience with that patient.

The legitimate problems need to be solved with good solutions -- not by lowering the standards.

[llg]

Yep. A lot of people would read our posts and consider us to be very politically incorrect... but I think a little politically incorrect thinking is exactly what is needed.

The nursing profession (in the US at least) is on the wrong path. The emporor is not wearing any clothes ... and some village fool (like me) needs to say so. I am thrilled to find out that you guys don't think I am such a fool after all.

As members of a practice discipline, nurses need BOTH kinds of education -- the theoretical and the practical. Neither should be sacrificed.

[*ac*]

Again, speaking as a recent grad of a highly rated BSN program... and in my first job for two months:

I was told, don't worry about skills - skills will come... it's critical thinking that you must learn in school.

Well, I started my job completely CLUELESS! I was SO embarrassed at how awkward I was/am.

My fundamentals clinical was exactly 2 days long - 2 short (maybe 6 hours) days. We did AM care on one patient, that was about it. Med-surg was 12 clinical days, but they were also only 6-8 hours each with a huge focus on medications. We had to know them inside and out. But we weren't allowed to mess with the IV pumps or anything.

So I started out not even knowing how to start maintenance fluids on a patient, not even how to read the fluid bags (for example, when told to get a bag of D5 and a 1/2 plus 20 of K, I was a deer in the headlights) - not even how to connect or prime the tubing... oh I could just go on and on...

The problem is that I am/was so slow with basic skills, d/t lack of practice, that I don't have time to "critically think". I guess it will come, but I would be getting so much more from the orientation time if I wasn't held back by having to learn to do such basic, simple stuff.

[elkpark]

Originally Posted by llg

Yep. A lot of people would read our posts and consider us to be very politically incorrect... but I think a little politically incorrect thinking is exactly what is needed.

The nursing profession (in the US at least) is on the wrong path. The emporor is not wearing any clothes ... and some village fool (like me) needs to say so. I am thrilled to find out that you guys don't think I am such a fool after all.

As members of a practice discipline, nurses need BOTH kinds of education -- the theoretical and the practical. Neither should be sacrificed.

(Just in case anyone's missed this so far, ) I completely agree with you. Put me down as another politically incorrect "fool." I want to stress again that I'm not in any way opposed to BSN education for nursing (or even making that the minimum entry level, if a majority of the nursing community ever decided to buy into that) -- just the way we're currently teaching nursing in BSN programs. It would be entirely possible to do a good job (what I would consider a good job, for what that's worth ) teaching nursing within BSN programs in colleges and universities; we just don't seem to be doing it now.

And (IMHO) TPTB need to quit buying into this "quicker/easier/cheaper" mentality about the value of coming up with "innovative" nursing programs. It's hard to be a nurse, and (that's why) it should be hard to become a nurse (and take a reasonable amount of time).

[jjjoy]

I with you all on this. Any thoughts on how we might have our voices heard in places where it might make some small influence? I checked local schools of nursing but none of the faculty seemed to have a focus on nursing education. I'm sure there are some conferences out there specifically on this, but I haven't been able to find them. I've considered trying to get involved in STS or ANA but am not sure where to start as most organizations like that that I've joined before weren't very participatory... just send in the money, get a membership card, and the right to note membership on resumes and the like.

It can be such an overwhelming topic! But it is nice to be able to discuss our concerns and experiences. I'm sure there are more of us out there who have similar concerns. Solutions don't seem easy, either.

I go round and round in my head over even what exactly the goal of nursing education should be! Should bedside nursing should be required for primary care advanced practice roles? What should the minimum level of education be for various nursing roles (eg long term care, sub-acute, hospital, ICU, clinics)? How does nursing relate to other allied health tech roles such as medical assistants, rad techs, resp techs, etc? How do we differentiate the roles and responsibilities of LPNs and RNs? Should having earned an RN equate with basic functionality in a bedside position? Or since so many nurses don't work in inpatient roles, do we even need to teach as much inpatient care for general nursing education and perhaps have further specialized training for acute/inpatient care? These are just a few questions.

Then, let's toss in questioning the relevance and utility of nursing diagnoses as they currently stand as well as the relevance and utility of the NCLEX in indicating minimum preparedness to be a licensed nurse... oh, yeah, and I have issues with how critical thinking is taught and conceptualized in nursing as well...

Whew!!! Where to start? Thanks for some comraderie in wrestling with these questions!

[SoundofMusic]

MORE camraderie is exactly what is needed in this profession. We NEED to talk through the issues -- not get defensive about LPNs vs. BSN's, or students vs. veteran nurses, or how the healthcare field is changing or whatever other mundane thing we can find to argue about.

There ARE solutions out there if people, particularly the women in this field, will stop being so down on each other and let people say what they feel and what they are experiencing, without condemnation and judgement.

I feel this thread has been very productive for that reason.

And if anyone is up to eliminating nursing diagnoses, I'm all for it!! I havent' seen ONE SINGLE NURSE even mention them in my short time as a nurse. They are a nice idea, but seriously, who has the time to develop them. We HAVE outcomes of care that work just fine.