[nursemike]

In my Sociology class (which, like Psych, I count as marginally nursing-related, unlike English or Pol Sci, which pretty much had nothing to do with nursing), we discussed the growing reliance on credentials in modern society. Going back to my carpentry experience, I was mostly self-employed (sort of--when your Dad is your partner, you're always the junior partner), but I did try a stint working for a larger outfit. Nice having someone else do the sales, bookkeeping, and worry about making payroll. Not so nice having to settle for the boss's standards, and when you do better work than they want you to, they get the credit. But what really got me was that so many of the other carpenters wanted to know right away where you went to school. I learned the trade the way Jesus did, working for my Dad.
I noticed that a lot of these guys were pretty competent at doing the things they learned in trade school. I remember some were pretty darned proud that they could read blueprints. Me, I taught myself how to draft blueprints, but more often, my "plans" were sketched on a scrap of 2x4, and, at least in remodeling work, you have to be able to adapt your plans to the situation before you. If your customer wants a bay window in a wall that has plumbing and electrical lines running through it, you either move the window or move the plumbing and electrical.
Getting back to nursing, as much as I hated careplans, I think I did learn a lot from doing them. In my first semester of Med-Surg, I nearly failed to advance because of my poor careplans. By the end of my second semester of Med-Surg, I could write an adequate (if only) careplan, and had a much better idea of "thinking like a nurse." But in my real world practice, I put checks by goals on a plan of care and initial whether they were met or not met. As for pre-planning, at a recent physical, my doctor asked whether I had any problems with ED. I thought a moment, and replied, "Not really. They give lousy report, but I do a full head-to-toe and take a history as soon as the patient arrives, anyway..."
Um, well, the point is, I don't get hours to review charts and labs on my patients before I get them. Not even the patients already established on my floor. I come in a little early to look over my Kardexes, listen to report, then do my assessments. I frequently have to adapt to the situation I find. If a patient had scattered rhonchi in report and is clear in all fields when I listen to him, I'm not doing NT suction on him. I'll have him TCDB a couple of times while he's awake and keep an eye on him, encourage incentive spirometry, and watch his dressing for CSF, because his chief complaint is the spinal decompression they did the day before.
The thing is, the careplans and concept maps and nursing diagnoses weren't useless. I learned a lot from them. They got me ready to be an apprentice nurse. But I learned (and still am learning) to think on my feet, adapt, improvise, and overcome, by working with nurses who were already doing it, and cared enough to help me. I don't disparage my instructors or my program. They got me started on the right foot. But the people that helped me take the next steps were "master nurses" (not MSNs) who jot notes on paper towels and empty gauze wrappers, and who are working with what's actually happening, rather than what's "supposed" to happen.

[RNperdiem]

I have heard of nursing programs requiring a CNA license. I wonder if it has to do with learning the basics of nursing.
While nursing school taught me to think like a nurse(plans and goals for a patient rather than a checklist of tasks to be done), my nursing assistant skills were well practiced from 4 years of work on a med/surg floor. I started my nursing overwhelmed as any new grad, but thankful for having learned the very basic skills prior to becoming a nurse.
SoundofMusic, I hope things improve for you.

[amj12]

I agree with the poster above. There were countless times I would prep the night before clinical to go in the next day and suprise my patient was discharged/transferred. Then I would have to do a quick once over the new pts. chart so I atleast had some idea of what was going on. Another thing, no matter how prepared we are when finishing nursing school the MAJORITY of every nurses learning comes from that first year out in the real world. Is it scary to think?!? Heck yea it is. I start my first job as an RN tomorrow and I'm terrified knowing that although my clinicals prepared me I basically know nothing b/c my learning is just beginning. There is so much to teach that it is impossible for a nursing program to teach you everything. So instead they give you the fundamentals and a hopefully solid foundation on which to build from once you have the RN behind your name.

[elkpark]

Originally Posted by amj12

Another thing, no matter how prepared we are when finishing nursing school the MAJORITY of every nurses learning comes from that first year out in the real world. Is it scary to think?!? Heck yea it is. I start my first job as an RN tomorrow and I'm terrified knowing that although my clinicals prepared me I basically know nothing b/c my learning is just beginning. There is so much to teach that it is impossible for a nursing program to teach you everything. So instead they give you the fundamentals and a hopefully solid foundation on which to build from once you have the RN behind your name.

But, IMHO, this is part of the problem (and I'm not singling you out personally in any way) -- this has become the great mantra of nursing: No one really learns much in nursing school but that's okay, because you learn what you really need to learn once you're out in the "real world," practicing; that first year of work is really a continuation of your basic nursing education, and everyone has kept saying that until it sounds like it's a reasonable thing to say. "On the job training" is what Florence Nightingale fought so hard to get away from 150 years ago -- and yet, now, we've come full circle and we're going back to OJT ... Hey, here's an idea -- if everyone's first year of work is a vitally important, necessary part of their nursing education, maybe nursing programs need to be a year longer!!

It wasn't that long ago (15-20 years) that nursing students really did learn in nursing school what they needed to know to function competently as entry-level nurses, you mastered skills sufficiently in school to be able to also think about what you were doing, and there was no such thing as these "externships" and extended orientations for new grads that everyone expects to be offered now, because there was no need for them. They are a phenomenon that has arisen out of necessity -- I have talked with lots of nursing administration people in lots of hospitals and, trust me, the hospitals are not happy that they have to teach new grad hires how to be nurses ... But the only other option is just to refuse to hire new grads, and they don't really have the heart to do that, either.

I would argue that it is precisely the "fundamentals" that many schools are not teaching now; they're teaching too much of the frosting, if you will, and not enough of the cake. So, when new graduates get licensed and start working, many of them don't have a solid foundation on which to build. I think that this, combined with the unrealistic expectations engendered by so many nursing programs, is why so many comparatively new nurses are leaving the field.

But I hope that won't be your experience! Congrats on your new job, and I hope you have a great day tomorrow!

[nursemike]

Originally Posted by amj12

I agree with the poster above. There were countless times I would prep the night before clinical to go in the next day and suprise my patient was discharged/transferred. Then I would have to do a quick once over the new pts. chart so I atleast had some idea of what was going on. Another thing, no matter how prepared we are when finishing nursing school the MAJORITY of every nurses learning comes from that first year out in the real world. Is it scary to think?!? Heck yea it is. I start my first job as an RN tomorrow and I'm terrified knowing that although my clinicals prepared me I basically know nothing b/c my learning is just beginning. There is so much to teach that it is impossible for a nursing program to teach you everything. So instead they give you the fundamentals and a hopefully solid foundation on which to build from once you have the RN behind your name.

Good luck. It is scary, but despite the overall trend of this thread, may I beg to remind you that you don't "know nothing." That is to say, you are a nurse, and you do know a lot. For all the challenges ahead of you, you have already passed a major one. Further, I know a number of 20 and 30 year nurses who'll tell you they are still learning every day. So, yes, you are building on that foundation, and, hopefully, you won't be doing it on your own.

One of the most surprising things I must have learned in nursing school, even though I'm not sure how it happened, is that before I went to school, there were nurses on my unit I wouldn't have trusted to watch my cat, but by the time I graduated, there wasn't one I couldn't learn from. Same nurses, different attitude. "Lazy" nurses who delegate every possible thing--but they're busy all the time, and their patients adore them. Mean, uncaring nurses crying in the Med Room over a pt's bad biopsy. Excellent nurses with superb teamwork and leadership skills, gently chiding me not to let management walk all over me. Honestly, I thought I knew these people, and some are still more my role models than others, but there was so much I never saw, until I was one of them. If you hit the floors with your eyes, ears, and mind open, you'll probably have days you wish you'd gone to truck-driving school, but you'll get through them.

[amj12]

Thanks. I know that I do know stuff. I wouldn't have graduated w/my stellar gpa otherwise , but in the relativity of nursing I still have so much to learn. Do I feel prepared? Absolutely. Am I still terrified of all the nurses out there that have been working for years and have already mastered the simple things that may take me an extra two minutes to do? You betcha. Being in the real world doing nursing now gives me the opportunity to take everything I learned (even those dreaded careplans we ALL hated doing in school) and put it to good use. It allows you to refine your assessment skills because now you are doing it on a more regular basis, gives you the opportunity to gain confidence in talking with doctors, and ultimately gives you the experience to be more comfortable in what you are doing. I feel like they say you learn so much in your first year not because nursing school is failing to properly prepare us, but because now you are doing this and you are seeing things you may not get the opportunity to see in school (i.e. procedures, diesease processes, cultures, and so on). Plus like nursemike said you get to learn from all of your colleagues b/c each one has something to offer.

[SoundofMusic]

Hey, here's an idea -- if everyone's first year of work is a vitally important, necessary part of their nursing education, maybe nursing programs need to be a year longer!!

Now that's an idea that makes sense. I don't know under whom nurses should work -- perhaps they shoudl be called "jr nurses" or "apprentice nurses" or something...but really, you're not really with it until a year has passed anyway -- so why load so much on a new grad to be a functioning nurse, when they really honestly can't be anywhere near such a thing?

[llg]

Originally Posted by SoundofMusic

Now that's an idea that makes sense. I don't know under whom nurses should work -- perhaps they shoudl be called "jr nurses" or "apprentice nurses" or something...but really, you're not really with it until a year has passed anyway -- so why load so much on a new grad to be a functioning nurse, when they really honestly can't be anywhere near such a thing?

I agree with that general idea ... but here are some of the problems that would come with trying to implement it. It has been tried in the past and the general idea has been resurrected again in the form of extended orientations and residencies for new grads.

The problem is money. (Surprise!) Who is going to pay for this extra year of training?
1. The school? Would they provide the preceptors, classes, debriefing sessions, etc.? They would pass the cost on to the students.

2. The students? Remember, these are the same students who complain about the cost of going to school now. How do you think the would respond to being asked to pay for their first 6 months or first year of practice? If "the system" would take that approach, they would probably not actually bill the students, but instead would pay them a smaller salary in the first year of practice -- a "junior wage," so to speak to compensate the hospital for the training they were receiving. How many new grads would be willing to accept a job that paid 20%-30% less than the job across town in exchange for a better orientation program? While I think it would be a good investment, I don't see many new grads being willing to do that.

An alternative that is being tried by some hospitals now is to provide that extra training in exchange for a contract that commits the recipient to work for that hospital for a given period of time. Those are becoming increasingly unpopular as nurses don't like working under a contract that prevents them form leaving a job in the event they change their mind. It works for a few people, but not for most people. If you search this website, you will find some threads in which people express outrage that a hospital would require some sort of "pay back" in exchange for a longer, more thorough education program.

3. The employer? That's where the responsibility lies now -- and hospitals are struggling to cope with it. They can't afford to pay for all this education to nurses who have the attitude, "If I don't like it, I'll leave." In order to make a 6-month or a full-year investment in someone's education, a hospital has a right to know that the nurse is going is going to stay long enough to be worth the investment. That means a contract of some type; and those are unpopular with nurses. (See #2 above.)

So, while we all agree that nursing students need more clinical experience than most get in school -- it's hard to find a workable solution that won't generate a lot of hard feelings in one group or another. Some tough choices will have to made and there will be "winners" and "losers" in the process of sorting it all out.

[elkpark]

Originally Posted by llg

I agree with that general idea ... but here are some of the problems that would come with trying to implement it. It has been tried in the past and the general idea has been resurrected again in the form of extended orientations and residencies for new grads.

The problem is money. (Surprise!) Who is going to pay for this extra year of training?
1. The school? Would they provide the preceptors, classes, debriefing sessions, etc.? They would pass the cost on to the students.

2. The students? Remember, these are the same students who complain about the cost of going to school now. How do you think the would respond to being asked to pay for their first 6 months or first year of practice? If "the system" would take that approach, they would probably not actually bill the students, but instead would pay them a smaller salary in the first year of practice -- a "junior wage," so to speak to compensate the hospital for the training they were receiving. How many new grads would be willing to accept a job that paid 20%-30% less than the job across town in exchange for a better orientation program? While I think it would be a good investment, I don't see many new grads being willing to do that.
An alternative that is being tried by some hospitals now is to provide that extra training in exchange for a contract that commits the recipient to work for that hospital for a given period of time. Those are becoming increasingly unpopular as nurses don't like working under a contract that prevents them form leaving a job in the event they change their mind. It works for a few people, but not for most people. If you search this website, you will find some threads in which people express outrage that a hospital would require some sort of "pay back" in exchange for a longer, more thorough education program.

3. The employer? That's where the responsibility lies now -- and hospitals are struggling to cope with it. They can't afford to pay for all this education to nurses who have the attitude, "If I don't like it, I'll leave." In order to make a 6-month or a full-year investment in someone's education, a hospital has a right to know that the nurse is going is going to stay long enough to be worth the investment. That means a contract of some type; and those are unpopular with nurses. (See #2 above.)

So, while we all agree that nursing students need more clinical experience than most get in school -- it's hard to find a workable solution that won't generate a lot of hard feelings in one group or another. Some tough choices will have to made and there will be "winners" and "losers" in the process of sorting it all out.

Actually, I was referring to just making nursing programs a year longer (like they used to be), with a proportionally greater amount of clinical time (more classroom time, too). Just more school.

Of course, #2 is exactly how physician residency programs work (but you knew that, didn't you, llg ) -- the residents get paid a minimal salary (enough to live on) in exchange for the work they do while completing their education. Maybe all the "how come nurses don't get taken seriously like doctors??" crowd would like to jump on this bandwagon (real nurse residencies). I think it's perfectly reasonable for employers to balk at paying new grads full salary for extended orientations and externships during which they not only produce only a fraction of the work an experienced nurse does, but incur significant training costs for the hospital (which, after all, is a hospital, not a nursing school). Maybe this could be a solution (although I would want to see it as a universal requirement for licensure, not a post-licensure option that students could choose to do or not -- joint efforts between nursing schools and hospitals (like medical residencies, again), that would have to meet specific, established standards to be credentialed. Not just any ol' hospital saying, "Sure, we'll get you for half price and say that we're educating you ...").

[SoundofMusic]

Well, I for one, like the idea of taking less of a salary if the expectations could be realistic and more humane that first year. If I could learn in an unfettered, unhostile, relatively unpressured environment, but actually be doing close to the real thing? That would be great!

Some may feel otherwise and be perfectly happy with things as they are -- but after going through an accelerated program and not feeling adequately prepared and putting up with downright abuse from professional nurses at times because I am so unprepared (not all the time -- just sometimes), I'd be all over this.

Maybe if there was an option to move through this period faster -- that would increase buy-in from more new grads.

I, however, would like to stay on the "slow track" option until I was absolutely ready to hit the ground running on the floor, the ICU, or whereever I could move on to after that time. I am just way too new to nursing coming from another field.

Oh well -- one can dream.

During this time, (oh, let me dream on a little more here ...) one could: 1. shadow techs for days at a time 2. Get to know the hospital ins and outs 3. Get to know the docs and how to communicate with them. 4. Follow pts. to procedures 5. Study the drugs particular to your unit in depth 6. Take weeks to learn basic nursing: IV's, blood draws, wound care, how to administer various meds, etc. I mean -- the list could go on and on.

It could backfire, though. Folks might be sort of undermotivated by the lesser pay and status -- I don't know.

Then again, if a hospital aggressively marketed this type of orientation -- I bet they'd have new grads flocking to them -- and would retain them, long-term. You could definitely eliminate the fright factor many new grads experience.