Made a fool of myself to board of nursing rep

  1. So, a representative from the California Board of Registered Nursing visited our school and asked us for feedback on our program. We had been encouraged to be on especially good behavior during the visit, but I couldn't keep my big mouth shut when the rep said that we should all be looking to the future to get our DNP degrees. I told her that I felt our BSN program seemed designed to push us towards grad school, but that I personally had no plans to become a nurse practitioner or to get an advanced nursing degree. I told her that I felt our program put too much emphasis on pathophysiology and clinical decision-making from the point of view of a physician or nurse practitioner and that we hardly spend any time in lecture discussing nursing procedures, nursing care, or the role of the nurse.

    The Board of Nursing representative looked at me as if I was crazy, like I had just complained that the sky was blue. She said it was all about pathophysiology and clinical decision-making "to anticipate the doctor's orders." Am I being ridiculous to expect that lectures will cover nursing care? Is actual nursing care so simple that it does not need to be taught in lecture? Or is it just understood that any nursing care will be learned in clinicals and on the job?

    I'm 75% of the way through my BSN program and I still can't wrap my head around how material is presented. It is always from the point of view of a physician; taking a history, doing a physical exam, deciding which diagnostics and lab tests to order, reviewing lab results, making a medical diagnosis, deciding which medications to administer, deciding whether the patient will need surgery and so on.

    There are never any phrases in our case studies or lectures such as, "Given these findings, what diagnostics would you expect the DOCTOR to order next?" Or, "Dr. Jones has prescribed amlodipine. Do you think amlodipine is the right medication for this patient?" It may have been stated by an instructor early in the program, but I cannot recall any instructor saying, "Now I know that you are nurses and that in real life you cannot prescribe medications except under certain protocols, but in this class we are going to present all material as if you were physicians so that you can understand how a physician thinks and therefore you will be able to realize if a physician has made a mistake in planning treatment for a patient."

    Instead, material is simply presented as if we ARE the doctors. It's very strange. It's like preparing to work at a hospital where there are no physicians, only nurses making all decisions. I get the idea of learning some pathophysiology and clinical decision-making to understand what's going on with the patient and how the medications work, but it just seems weird that I am expected to make medical diagnoses and prescribe medications without going through the more extensive pathophysiology and pharmacology training that physicians are given. I feel like I'm already being pushed to become a nurse practitioner before I've even finished RN school.

    Is this normal for a BSN program? How can I adjust my thinking so that I don't feel frustrated? Thank you very much for any advice.
    Last edit by sirI on Nov 29 : Reason: Threads merged
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  2. 46 Comments

  3. by   FuturePsychNP21
    "Nursing care," which I'm guessing means skills and hands-on work to you, is something you should be learning in clinicals. The point of lecture isn't to teach those things but to help you understand WHY you are doing them. What is going on with the body that requires you to administer certain medication or see a certain presentation during an assessment. You have to learn exactly what the physicians will be doing and why because it will be your job to make sure their orders are appropriate for the patient and question the order when they are not since you are the one carrying out the orders.
  4. by   Lemon Bars
    Thank you for the response, FuturePsychNP21.
  5. by   Sour Lemon
    That all sounds appropriate, to me. Maybe after you actually do the job it will make more sense to you. You're getting nothing remotely close to a physician's education. Don't worry.
  6. by   klone
    Gone are the days when nurses are physicians' handmaidens and we blindly follow orders. You need to know much of what the physician knows so you know whether or not it's an appropriate med/treatment/intervention. If you carry out an inappropriate order, YOUR license is on the line.

    And yes, pathophysiology is incredibly important to know. Nursing is not tasks.
  7. by   JKL33
    Quote from Lemon Bars
    I get the idea of learning some pathophysiology and clinical decision-making to understand what's going on with the patient and how the medications work, but it just seems weird that I am expected to make medical diagnoses and prescribe medications without going through the more extensive pathophysiology and pharmacology training that physicians are given. I feel like I'm already being pushed to become a nurse practitioner before I've even finished RN school.

    Is this normal for a BSN program? How can I adjust my thinking so that I don't feel frustrated? Thank you very much for any advice.
    I'm not trying to question you if they are indeed using verbiage such as "what would you diagnose" - which, by the way is an entirely different implication than asking what condition you believe a patient might be diagnosed with...

    Just the same, are you sure you haven't misunderstood? You need to know which signs and symptoms go with which diagnoses for very practical nursing-related reasons. You need to know which medications/doseages/routes/frequencies are used for very practical, nursing-related reasons. You need to know more than "some" pathophys and pharmacology for very practical, nursing-related reasons. If you ask me, having a good knowledge base in these things are what oftentimes separates nurses who are excellent vs. good vs. not good. Of course there's much more to nursing, but it's hard to get to that when you don't have a good idea what's going on and/or can't use assessment to come up with reasonable conclusions.

    If your concern is that your program is light on the specifics of nursing, that's a different problem. Are there nursing-specific things that you feel you aren't being taught?
  8. by   Scottishtape
    Klone hit the nail on the head. You will not, and should not be blindly following orders because the physicians are the ones who put in orders.

    Understanding pathophysiology and being able to figure out what's happening with your patient allows them to be treated quicker and more efficiently. It allows you to better care for them as well.

    Every single day on my unit, I round with physicians and it's never just them assessing the patient and just giving me orders. We discuss the patient's case *together* and come up with a plan *together*.

    Example: I had a patient a few days ago who has no history of kidney disease, yet he hasn't urinated a lot duringy shift. I knew this because I had been *assessing* him all day. I understand the *pathophysiology* so I was able to take action. I went and grabbed the ladder scanner to see if he was retaining or if he just plain wasn't drinking enough.

    Turns out he had retained a bunch of urine in his bladder. I then straight cath'd him (we have policies in place that allows this) Why? Because I knew that not only would this cause him discomfort, but that it would damage the bladder had it continued. Off the top of my head, I could think of about 5 different things that could be going on with my patient that would cause this. I assessed him further, called the attending, and we came up with a game plan.

    That is the role of the nurse. It happens everyday, everywhere.

    You need to understand and get sharp at assessments. Small changes can indicate large issues that you'll miss if you're not assessing properly.

    You need to understand how to read diagnostics and lab results. You'll be the one following up on the care (patient has a potassium of 2.5 - you need to know what to do) Patient has a diagnostic come back showing a small bowel obstruction - you'll know that you're going to need to place them NPO and prepare for surgery.

    There is so much more to nursing than random tasks throughout the day. The job, when done correctly, is much more mental than physical.

    My advice: stop bemoaning the thought of advanced education and focus on your current level and what they're teaching you. If you don't, you can be placing your patients at unnecessary risk because you thought you knew a nurses job better than those who were trying to teach you.
  9. by   missmollie
    Nursing tasks are not the definition of nursing. Anyone can learn to cath, place an IV, rectal tube, do trach care and so on. The reason we are professionals is because we are the last person between the patient and bad outcomes.

    -You will find medication errors that could have been deadly when both the doctor and the pharmacist have overlooked an allergy.
    -You will be the one alerting the doctor to a critical lab result, because you will be waiting for those lab results to come back.
    -You will be the one who finds that kidneys are shutting down, that the patient has a cardiac issue, that the patient is bleeding internally. Patho will get you there.

    And before you go on the floor as a brand new nurse, thinking that you've been taught everything there is to know about nursing, you don't. You know enough to barely practice safe nursing. You know nothing, but you will think you do. That first year is scary, and you won't even realize it was scary until you reflect back on it a year later.

    Oh, and nursing is completely worth it, despite all the studying and stress, the bad patients and families, the feeling of inadequacy during that first year. I promise you it is a fulfilling career.
  10. by   umbdude
    Agree with all the examples.

    Some (if not many) of your patients will ask you and expect you to know about why they're experiencing certain symptoms and why they're taking certain meds and how they work. You need to educate them and/or their families about the meds, side effects, and what key things to look for.

    My BSN program encouraged us to get higher education, but more for personal fulfillment and to advance the profession. Good educators often want to see their students reach for the stars. It's not unusual. Also, in many cases you can do more for patients with more knowledge and credentials. However, if you don't want to go back to school, they cannot force you to do so.
  11. by   Lisacar130
    It's really just about the way it's worded. An answer could read "give lasix" or it could be worded "get order from doctor for lasix" but it's the same learning concept. They are probably just trying to prep your mind to think like a nurse practitioner but if you aren't going that route then don't think too much about it.
    BSN Programs are known to be more theory based then practical hands on skills. They explained it to us as this: anyone can be taught how to start an IV. You'll learn that on the job. We're here to teach you theories and concepts. When you graduate, the associates degree nurse will be better than you at starting IV's, but in time there won't be a difference. But you will have more knowledge in other areas that will help you advance your careers.
    You'll get like a 3 month training at a new job if you work in a hospital. There will be plenty of opportunities to practice the hands on stuff. Your preceptor will have an easier time teaching you how to start a foley than explaining multiple patho/pharmacology concepts so now is your time to learn about that. The other hands on stuff can be learned easily on the job.
  12. by   LovingLife123
    You are being taught to critically think. And while we don't necessarily write the orders, we often put them in. As others have stated, once you work on the floor, you will see. We collaborate with the physicians.

    I was rounding with one of our physicians last week. He came in right at shift change and I gave the lowdown of what I had gotten in report from the night shift nurse. I had yet to do my assessment but knew something was off on my patient and the physician said he vastly different from 48 hours ago.

    I had time to assess my patient, look at labs, and look at history slightly. I call him back and say now that I've done my assessment, here is what I am seeing, and here is what I need to start. He says ok, let's do A, B, and C and see what we find. It was a team effort.

    Lots happened with that patient as he was declining. I had to know my labs and my patho to get a clear picture of what was going on with the patient.

    Let me also explain most physicians specialize. Most patients have more than one discipline following. The neurosurgeon doesn't care a whole that your patient hasn't pooped for a week. The Orthopedic surgeon doesn't care much that you have new onset unequal pupils. Each doctor focuses on their speciality. You as the nurse, focus on the whole picture. Then you can put it all together for the physicians.
  13. by   Lemon Bars
    Thank you so much for these responses. I'm going to address some things to hopefully further the discussion, but please know that I'm not trying to be stubborn or snarky.

    "I'm not trying to question you if they are indeed using verbiage such as "what would you diagnose" - which, by the way is an entirely different implication than asking what condition you believe a patient might be diagnosed with..."

    My instructors are indeed using verbiage as if we are directly responsible for making the medical diagnosis and prescribing the medication. Many of my instructors are nurse practitioners, and it makes me wonder if they are unable to step out of the provider role.

    "Nursing tasks are not the definition of nursing. Anyone can learn to cath, place an IV, rectal tube, do trach care and so on...And before you go on the floor as a brand new nurse, thinking that you've been taught everything there is to know about nursing, you don't. You know enough to barely practice safe nursing. You know nothing, but you will think you do."

    Well, it's been two years and I've only done two urinary catheters and three successful IV sticks. I've given a grand total of one IV push medication. I hung my first IV medication and programmed a real IV pump for the first time just a couple of weeks ago. I've only helped change a bandage three or four times. I've never done a rectal tube, never done trach care, never set up a chest tube drainage system, never touched a ventilator, never drawn a blood sample, never collected a sputum specimen, and never done a nasal swab. There are probably a dozens of nursing tasks that I am unaware of or unfamiliar with. I certainly don't feel like I know everything. As it stands right now, I feel incompetent when it comes to many actual nursing tasks in the hospital.

    "If your concern is that your program is light on the specifics of nursing, that's a different problem. Are there nursing-specific things that you feel you aren't being taught?"

    As I mentioned above, there are many nursing tasks that I have not practiced. But here's a different example of what I mean: We do case studies and we have a patient with such and such history and who presents with certain symptoms. These patients have always just arrived at the ED in need of an accurate medical diagnosis and treatment. It's not the case that these patients already have a medical diagnosis and are now being transferred into our care on the floor. They are fresh patients who need a complete medical workup by a medical provider before they can be admitted into the hospital. We take the history and do the medical workup from the perspective of the physician.

    In the second half of class, we have a discussion about how we treated the patient. Let's say we make a mistake; we give an anticoagulant to a patient who has a low platelet count and is already at grave risk of bleeding. Our instructor will talk about how we should have known about the low platelet lab value and that we should have prescribed a different medication or tried a different treatment first. Missing from the discussion is how a real nurse would handle a real situation such as this. Missing is guidance on the nursing role such as, "Okay let's say Dr. Smith ordered the anticoagulant, but now you've checked the labs and the platelet count is too low, what will you say to Dr. Smith and what alternative medication or treatment could you propose to Dr. Smith that would be more beneficial to your patient." Rarely or never hearing about the role of the nurse in lectures and discussions is causing me confusion and anxiety. (However, we do have a simulation class where this type of interaction with a physician is simulated and practiced. So I'm finally starting to get the idea of how this all works.)

    Is my point of view starting to make sense? I expect clear explanations for why I'm learning what I'm learning and how I will put the knowledge to use in my work. I expect to know how to function in my role as a nurse when I graduate from my nursing program.
  14. by   llg
    I think that you might be right about linking the style of teaching with the fact that most of your instructors are Nurse Practitioners. For some people, "nurse" has become almost synonymous with "nurse practitioner." I think that you are making a valid point that should be taken seriously.

    The fact that you have done a few caths, started an IV, etc. is good. Nursing technical skills are important, too, and too many programs have failed to teach them well enough. However, there is no need to do 100 of them -- a few should be sufficient to introduce you to the skills and your employer should be able to give you additional practice with them after teaching you their particular protocols and procedure statndards. But you should be getting class material on the science behind these skills so that you understand the skills.

    So ... I think you raise a legitimate concern. In many schools, the pendulum has swung to far in the NP direction. Entry level programs should not be teaching from an NP perspective and/or teaching the NP role (unless they are entry-level NP programs). They should be teaching staff nurses skills from a staff nurse role perspective.

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