Seasoned Nurses VS Newbie Nurses

[Alexx_xox]

As I've stated in multiple other posts, I am a new grad in the ER. As a new grad, I do not possess the EXPERIENCE that a seasoned nurse has; however, I have noticed that many seasoned nurses are not up to date with new standards that were taught to us in school.

How can one bridge the gap between old knowledge vs newer knowledge?

Here is a perfect example. We were doing ACLS and all the new grads were very knowledgeable regarding the new ACLS protocol; however, a more seasoned nurse was there as well and was following a different protocol that was practiced years ago and not up to date.

With preceptorship coming soon, how do I as a new grad decide what to follow as far as their experience and advice, versus what was taught to me in school?

I am not talking about ACLS protocol here; OBVIOUSLY I am going to follow what the AHA recommends, but I am talking other things here for instance:

-skills

-assessments

-charting

etc.

I have noticed seasoned nurses also don't chart the same as newer nurses, especially because when they had originally started, there was no such thing as an online charting system.

I respect all seasoned nurses and love learning from them and their knowledge is absolutely invaluable, but I have noticed a lot of discrepancies between what we learn and what they do.

Any advice?

[nursel56]

Hi Alexx-- my thoughts are that there's nothing wrong with observing other nurses and making mental notes about what we see. I've done that since I was a nursing student.

What I've learned is that it all comes down to the individual, and I try not to "pigeonhole" anybody based on a descriptor. It doesn't matter how long someone has been a nurse.

If you observe something that's an obvious risk to patient safety, you're obligated to report it, but other than than that, you should be fine.

[brandy1017, ASN, RN]

As to ACLS you'll find frequent changes in protocol with each new 2 year recert. They are constantly looking to find better ways to bring someone back from the dead so expect change.

As to doing things different than school, in real life you are juggling multiple patients and in the ER there may be no limit, depending on how many peeps rush into ER and how many patients they are holding down there waiting for a bed in ICU or the floor so perfect charting takes a back seat to keeping patients safe and alive! You'll find older nurses chart less, the young ones usually over chart because that is what they are taught and they are worried about making a mistake or being sued!

Truthfully there isn't time to chart perfectly and do everything to the latest protocol that some think tank educator comes up with. This brings to mind the micromanagement another ER nurse mentioned in the article here Knaves, fools, and the pitfalls of micromanagement and how new nurses were documenting to a T, but in the process patient's safety and real life needs were being put on the back burner. I wouldn't want to work in that ER when the pressure to do everything perfectly according to someone sitting in an ivory tower takes precedence over actual patient acuity and safety!

Sadly while the protocols are meant for best practice and some spurred on by medicare demands and reimbursement, they are not always realistic due to the time constraints, number of patients and the need to keep everyone safe. All you can do is do your best to follow the protocols while keeping patients safe. I would give stroke and MI protocols top billing over others as time is muscle and may make the difference between life and death! Also the post code hypothermia protocol may make the difference between a high quality normal life to those who survive a code!

[BrandonLPN, LPN]

Well, admittedly, the responses here suggest that we seasoned nurses are a bit touchy when it's implied our practice is outdated. But the responses you got also suggest that you didn't choose your words very carefully. Trust me.... ten years from now, reading a post like your OP from a new-ish nurse will make you bristle, too.

In any event, I think you're overthinking it. No two nurses have the exact same practice. It's not even necessarily a matter of some nurses being more "up to date" than others. Even new nurses who graduated the same year as you may have learned very different techniques if they attended a different nursing program. Sure, some of the practices you learned in school may be better than what you see the COBs (Crusty Old Bats)doing on your floor. But some of the practices of the COBs may be better than your school's. Really, most of them won't be "better" or "worse", just "different". Common sense and your own preferences will generally tell you whether to do it like your old instructor, or do it like the nurse currently precepting you.

[Alex Egan, LPN, EMT-B]

I was an EMT before I was a nurse. The learning curb from EMT class to the practice is severe, and I tripped on it very hard. I pissed a lot of people off, and made myself look bad a lot. It was all because I didn't know what I didn't know. I knew a lot from class but I didn't know I had a lot to learn. I had a good preceptor, and a few hard partners and when I got to nursing school I vowed not to do that again. I oriented with a few different people, I took with worked, left what didn't. I picked up same bad habbets and learnt that shortcuts aren't always good for me. In the end my transition to nursing was easier because I followed the motto "I will learn your ways, take the best, leave the rest, and make my practice mine, as soon as I know which way is up"

It wording in your original post is a little standoffish. Because as with nursing you don't know that we have this topic every year, every year someone comes and tells us how bad all their preceptors are. It's easy for the crusty amongt is to be easily offended by sick posts, but we all did it to to some extent or another.

[Crush]

some of the practices you learned in school may be better than what you see the COBs (Crusty Old Bats)doing on your floor. But some of the practices of the COBs may be better than your school's. Really, most of them won't be "better" or "worse", just "different".

There is always something we can learn from each other, regardless of the length of time we have been a nurse. Just remember that different styles are not necessarily "bad", just different.

I recall thinking the same thing right out of nursing school. I think making observations and incorporating what you learned through nursing school plus adding in some helpful tips and such from the more experienced nurses will be very helpful in the long run.

[SpankedInPittsburgh, DNP, RN]

My advice is don't critique your preceptor. He/she has been in the ER long enough to be respected and trusted to precept you. Nurses in the ER have exceptionally long memories and this will be thought of as disrespectful at the very least. Unless they are going to make a mistake that will have an adverse patient event suck it up. You can add your nuisances to your practice when you are on your own.

[maxthecat]

This is why school emphasizes learning how to critically think. Evaluate each way of doing something and decide if one way is better or if it really comes down to personal preference and act accordingly.

[TriciaJ, RN]

My advice is don't critique your preceptor. He/she has been in the ER long enough to be respected and trusted to precept you. Nurses in the ER have exceptionally long memories and this will be thought of as disrespectful at the very least. Unless they are going to make a mistake that will have an adverse patient event suck it up. You can add your nuisances to your practice when you are on your own.

You probably mean nuances. Administration likes to add the nuisances. :)

[Neats, BSN]

We are each individuals. Any new updated Nursing skills I am sure will be made soon enough. Unless it is a matter of life and death I would not place so much focus on it. Renewal of CPR/advanced CPR will be made, Clinical competencies will be relearned. and I think you will find a variety of different ways one can accomplish the goal, again is it really such a life and death need to say something. If it is then by all means speak up, if not just observe and learn.

When I first took A&P there was only one paragraph related to HIV in the book, it was unknown. I learned more about it in the work environment and of course when I took A&P over again.

New is not always better it is just different. I would cooperate and graduate your preceptor time and then begin your nursing practice within your scope of responsibility. There is no need to compare/question/and assume your way is better because it is new and current. Unless it is mandated to perform a specific task in a specific way why worry about it? Think about this... 5 years from now when you are a preceptor and a new nurse is following you around they will be saying the same thing about you.

[MotherOfBoys]

I am a new grad RN and have experienced the same thing when I was going through orientation. My preceptor has been an LPN for many years and had only been an RN for about a year. Yes a lot of the things she had done were not the same as I was taught in school. Most of the time I would just accept the opportunity to learn how to do something a different way. If I was questionable about something I would do my own research before even thinking about mentioning it. The only time I did say something was when we were putting in a foley and she kept missing the right spot and would pull it out and put it right back in with stuff all over it. Totally not sterile technique. Now that I have been off of orientation I do things mostly how I was taught in nursing school as I found they are more efficient than what my preceptor taught me. But once your on your own you kind of figure out your own way of doing things. I still ask questions all the time to more seasoned nurses.

[Here.I.Stand, BSN, RN]

You do realize that all nurses have to renew our ACLS/BLS q 2 yrs, right? Which specific protocol was the "seasoned" nurse not "up to date" on?

One thought I have on this is, not every RN actually needs ACLS. Was this experienced RN taking the class after many years in med-surg or subacute? If that's the case, it isn't an issue of not keeping up-to-date -- of COURSE she wouldn't be up-to-date on ACLS protocols.

And as several page 1 replies state (as of now, I have only read the 1st page) -- real life nursing can look different than nursing school textbooks. A couple of examples:

1) verifying NG/OG placement: where I work we never verify placement with an x-ray. If we aspirate gastric contents, we're good to go. We almost never feed through an NG/OG -- we feed through an NJ; THAT is always x-rayed to verify it's post-pyloric. But not the NG/OG which is only used to keep stomach empty of gastric secretions.

2) AHA rec's for SBE prophylaxis. My older son has a bicuspid aortic valve/AV regurg. Several years ago, the AHA stopped recommending prophylactic antibiotics for oral or GU procedures, except for complex CHD. HIS cardiologist however, has anecdotally seen more cases of SBE in the defect my son has. SHE (a med school professor of peds cardiology, I'll add) opts to err on the side of caution, and continues his Rx for prn amoxicillin.

3) metoprolol parameters. In school it was drilled into us "hold for SBP

4) tPA given to young stroke pts, even if outside the window, or even if stroke isn't proven (unless a bleed IS proven, of course.) The neurologists have felt that their risk of a hemorrhagic conversion is low in the under-40 set, and the benefit outweighs the risk.

5) Q 2 hr turns: yes we understood that pts are at risk for skin breakdown if not repositioned... but some people are too unstable to tolerate repositioning. That will become obvious as you gain more experience with critical pts.

None of those deviations reflect outdated standards; they reflect the reality of PATIENTS whose bodies haven't read the textbook.

If you are concerned about any overlooked "best practices," I would encourage you to reach out to the hospital's nurse educator. ASK why the said practice is used -- don't assume you truly know better. One of two things will happen: either the experienced RN will be educated, or you will.

[Isabelm1122, BSN, RN]

I don't usually post here, but I had to speak up after reading some of these comments.

The nasty attitudes on this post are the reason I'm starting to feel disappointed in the nursing profession. I'm about to be a new grad RN in a brand new job, and instead of being passionate and excited to learn, all I can think about is trying to find a job where the nurses aren't nasty to each other.

Alex is bringing up something that is pounded to our head in nursing school- using evidence based practice. An amazing example of seasoned nurses transforming seamlessly into newer, safer practices: our nursing school instructors! They're adapting to the latest research in order to teach us the most current evidence based nursing practices.

I can see, from my clinical experience, how this concept is quickly forgotten in the real world. I can also see that seasoned nurses have an incredible amount of real world experience that, hey, if it's worked for 20 years with good patient outcomes... keep doing it!!!! My mother is a very seasoned critical care nurse, and I trust her judgement in a profound way... she is sage in the world of nursing - and I am sure to ask her advice as often as I can. However, if a newer, safer practice exists, it's worth bringing awareness to!

New or seasoned, patient safety will always remain paramount, and I think that is what Alex was trying to get at in this discussion post. I wish that nurses, as a community, could spend more time lifting each other up and helping one another learn (new practice, and seasoned, very valuable practice!) instead of throwing egos around the halls of our facilities and creating ugly environments for us new nurses to try to learn in.

Xo

Isabel