Are nurses who work in hospitals with limited resources better?

[zahryia, LPN]

I recently started doing per diem in a community hospital that's not considered a 'real' hospital in the eyes of some of the nurses on my floor. I think this is due to the limited pharmacy/cafeteria hours and relatively low census.

I came from a huge academic hospital in the DC area and even did a short stint at a famous hospital in the Bmore area as a student nurse.

I'm finding that I'm honing my clinical skills at this communnity hospital because there are limited resources. I'm having to mix my own drugs, do more IVs, and use more 'wrap arounds' than all I had to do at my other academics hospitals. I don't have access to all the latest gadgets and I don't have to compete with residents to learn new skills. I'm having to rely more on critical thinking because partly because I don't have a choice!

So while it can be annoying and inconvenient sometimes, I find myself learning at a faster rate and becoming more independent.

Any thoughts?

[llg, PhD, RN]

You make a good point -- though perhaps you should not say that one group of nurses is "better" than another. It all depends on how you define "better."

But the need to be more independent and creative in your thinking is probably a valid point. It's similar to the dissatisfaction that older nurses have with many younger nurses. The older nurses learned skills "back in the olden days" before everything was computerized and support services took care of much of the work that nurses used to do -- skills that today's young nurses have not learned in school. It's hard to explain the value of those skills to people who have never "seen" or "felt" them.

The lack of those skills is also one reason why well-meaning but inexperienced nurses are not as helpful in disaster situations (such as Haiti) as they would like to be.

[PostOpPrincess, BSN, RN]

You make a good point -- though perhaps you should not say that one group of nurses is "better" than another. It all depends on how you define "better."

But the need to be more independent and creative in your thinking is probably a valid point. It's similar to the dissatisfaction that older nurses have with many younger nurses. The older nurses learned skills "back in the olden days" before everything was computerized and support services took care of much of the work that nurses used to do -- skills that today's young nurses have not learned in school. It's hard to explain the value of those skills to people who have never "seen" or "felt" them.

The lack of those skills is also one reason why well-meaning but inexperienced nurses are not as helpful in disaster situations (such as Haiti) as they would like to be.

As an experienced nurse, I can tell you right now, I am glad I learned the "old way." I have attained many skills that no longer are in my current scope of practice, whereas it used to be.

I kind of feel bad for today's crops of nurses.

[zahryia, LPN]

You make a good point -- though perhaps you should not say that one group of nurses is "better" than another. It all depends on how you define "better."

But the need to be more independent and creative in your thinking is probably a valid point. It's similar to the dissatisfaction that older nurses have with many younger nurses. The older nurses learned skills "back in the olden days" before everything was computerized and support services took care of much of the work that nurses used to do -- skills that today's young nurses have not learned in school. It's hard to explain the value of those skills to people who have never "seen" or "felt" them.

The lack of those skills is also one reason why well-meaning but inexperienced nurses are not as helpful in disaster situations (such as Haiti) as they would like to be.

Exactly! I was thinking the same thing. Or even a situation like Katrina where you would've had to use gtt instead of a pump due to lack of electricity. Even though I learned the formula in nursing school, I haven't had a situation where I've had to use it in real life.

I'm starting to value these 'older' skills.

[BULLYDAWGRN, RN]

I just believe you tend to practice a certain style of nursing that fits your own personality and beliefs. however, the way you nurse can and most often is dictated by the enviroment you are in. at my full-time job, we have no resp therapist assigned soley to our unit and we have had to wait several minutes before one could responed for emergencies. we dont have 3rd or 4th yr residents sleeping in a room outside the unit we can bother in the middle of the night. so we have become acustomed to trouble shooting many a situation until helps arrives. which i think is good to a certain extent of course. now i work a part-time job where the unit has its own dedicated support staff from other depts and med residents hanging around & i'm gratefull for their presence. I may not be hands on trouble shootin vents and drawin abg's and such, but i'm able to take a step back from situations such as that and allow other care givers to do their own thing and to tell you the truth it's refreshing. i find myself learning new and different techniques and rationales that i take back to my "do it yourself" job. like i said, i think the place you work will tend to help mold how you nurse, wheather thats a good thing or bad depends.

[Wildschmidt]

At our rural hospital, there are usually 1 or 2 nurses in the ER, a couple more on the floor, and a physician on call but not always present. No "teams" to do any skills - they have to get every IV stick, know every drug, every procedure, and be able to stabilize any patient by themselves!

It's a tall order and I know they have a hard time finding nurses who have that level of experience. I'm still just a student but it's intimidating to watch the level that is required. Oh yeah, and they pay less than any urban hospital and the hours are less flexible. Then policy makers wonder why we have a shortage of nurses in rural areas!!

[RNnoelle]

That sounds exactly like the hospital I work at now. It's my first nursing job so I have nothing to compare it to. I don't plan on working there for more than 2 years since it is so small and I'm not sure if I'm getting all the experience I need. The majority of the nurses working there now haven't worked at any other hospital so they can't tell me how different it would be anywhere else. For now, I'm just trying to make the best of it and learn all I can from the more experienced nurses.

[RNperdiem, RN]

I like your attitude about this. Where other nurses might find a situation to grumble about, you found the positives.

I do know about losing certain skills. I haven't mixed drips in years now. The IV pumps have lots of programming features now, and the equations are not used as much to calculate.

I worked at a community hospital where the pharmacist locked up the pharmacy at 10pm and went home. If you needed a drug not on your floor after hours, the house supervisor would unlock the pharmacy and the two of you would go looking.

[Indy, LPN, LVN]

My ICU experience (still my prn job) is in just such a hospital. My only grumble about it is that the physicians will keep an MI there even if they aren't an elderly DNR. There are cardiac centers close by in two directions.

We do too much without central lines, we don't have night cafeteria or pharmacy, we mix drips regularly with the exception of narc drips and/or epidural bags. Sometimes the physicians forget that we don't have every drug on the planet available. We have levophed, but alas, no neosynephrine. No amount of whining over how it is the only drug that will work, will make me suddenly find it in a closet somewhere. Then of course the doc doesn't give transfer orders and lets the management know the nurse was unhelpful. On an elderly DNR patient. :-)

I learned milk and molasses enemas there, we do drips with no such thing as Dose Mode, and we do them right! No experienced nurses will come up for help on the drip rates without first doing their OWN math. I love it! The downside these days is they are getting busier without having reinstated their night shift respiratory therapist.

Skills wise, without intubating someone, you do a lot more pulmonary interventions than you would in a hospital with fulltime RRT's, you know the ins and outs of which mask, what flow, you do CPT and IS without having to be told, ditto for NT suction. Also you ambulate and give prune juice for constipation. The hospital that is my full time job does not buy prune juice! Seriously. We keep up with cumulative in/outs and do daily weights- again this is just part of the routine. I do consider all my skills honed well, with this experience. I keep going back now and then to keep my tele skills up, since that's also part of the job.

Cons. Well I couldn't deal with a swan to save my life, never even seen the thing. I can run a pressure bag and/or a CVP line, but have to be shown how to make the monitor do it's part. I only have experience with one type of insulin drip and it tends to drop sugars suddenly at one point in its algorithm, not to mention changing iv fluids several times inside of four hours in the really sick patients. The new job has some funky chart that apparently corresponds to what the Glucomander would have you do. Having not seen a glucomander, I have thoughts of some terminator-style robot that commands my every move. So mostly, it's the newest and most wonderful equipment that I lack experience with- but for your basics I'm your gal, and I will not have a patient crash on my assignment that I did not at least warn the charge nurse about, and probably call the doc about as well, beforehand. I look for trouble and if I don't see it coming, it's a rare day.

[Ivanna_Nurse, BSN, RN]

I work in large hospital (32 bed ICU) that has intensivists, insulin and electrolyte protocols, rapid response teams and lots of fancy gadgets. If there is a code... 2 docs, echo, xray, 2 resp therapists and a handful of staff are there in a second. My patients do well, and if I feel like they arent, all I have to say is.. can you look at my patient in bed 4? Pharmacy and Cafeteria all night long, as well as environmental and transport.

This is not where I came from however. I came from a small community hospital, with an 8 bed ICU. No xigris, arctic sun or agatroban. No cath lab, CVVH, or IABP. There is one ER doc, one ER nurse, one resp therapist. The ICU nurse doubles as the rapid response team, and runs the codes until the doc and resp therapist arrive.

Completely different... but all those late night vigils, watching patients and going with my gut, calling in wee hours of the morning with changes in assessment. Running codes and evaluating patients on the floor, functioning as PACU late at night... that has taught me so much.

My patients are sicker and we do more, but I feel like I was blessed with a start in a small place. My assessment skills rock, because they had to. ~Ivanna

[husker_rn, RN]

My first job out of nursing school was a rural hospital that staffed one nurse and one cna per shift; I had worked as a cna in a different rural hospital while in school. It was a wonderful learning experience. I learned to be creative with the limited resources we had. We were a stabilize and ship hospital for the most part but quickly recognizing what we were looking at was critical. I very much understand the point you were trying to make Ivanna_ Nurse and very much agree with it.

[meadow85]

I've worked in a community hospital and a teaching hospital in the city and have found a difference. I learned a lot while working in the community ... my mentor has noticed my growth as well. I'm a better nurse for it. You learn to work w/what you have and it really develops your skills. Although it can be frustrating at times when you feel lack of support, resources, morale we are all working towards a common goal. These patients are a lot sicker and need us more. In saying that, I did miss the opportunities that the city offered though so I am thinking of going back.