I was asked to conduct courtesy interviews for several new nurses who were not able to obtain a job as a nurse. These nurses had graduated in 2009, 2010 and 2011.
It was interesting to speak with them as they were hopeful that a job would come their way.
What did concern me was that these nurses did not understand that they are not practice ready. By practice ready, I mean being able to go on the floor, get report and get to work as either a staff or charge nurse.
The nurses I spoke with had their degree and a license to practice but no paid experience. Volunteer experience is a great way to make contacts but it is not the backbone of a resume.
I explained to the nurses how tight positions for nurses are and that more belt tightening will be occurring in healthcare in the region (NYC).
All the nurses were under the impression that once they got their RN they could do what they wanted professionally. The expectations they have about the nursing profession are very inflated.
The changes over the last several years are having a cumulative effect...schools are graduating too many nurses for too few positions. As new nurses are graduated, the previous years graduates become more unlikely to get a nursing job. Skills fade when not used plus employers would rather take a new nurse straight out of school rather than a nurse who has been on the side lines.
Nursing schools base their educational program on the assumption that their graduates will be employed in a hospital. The hospital will prepare the graduate nurse to function as a staff nurse via new nurse orientation programs and preceptor programs. Due to the problems in the economy which has been effecting facilities since the 2007 recession, positions have been reduce or eliminated, turnover is down, fiscal issues are becoming a priority effecting everyone in healthcare.
New nurses are expensive to train and orient. My personal feelings is that if the schools did a better job preparing students to practice, the graduates would have a better chance to secure gainful employment. We all know of nurses who got a job as a nurse in a hospital, went through a lengthy & costly orientation only to realize nursing is not for them. Some of these nurse will bounce from job to job hoping their next employer will be different. It sad to say but it is the same everywhere...just different characters. In the era of a nursing shortage, new nurses could do this, today it is a different ball game.
I told the nurses the standard advice: keep applying, volunteer, get a BSN or other training, etc. The sad fact is if these woman need to be working not on the sidelines hoping that jobs will be opening up in the next few months.
I firmly believe if the schools had prepared the nurses for practice, the nurses would have a better chance in the job market. I also firmly believe that nursing schools need to prepare nurses for the future of nursing practice...community health, home health, LTC, public health and outpatient and clinic practices. Schools don't play up these areas but these are the areas that nurses in the future will be working. Hospitals will become leaner with more treat and street services.
Anyway, this is my thoughts on this subject. I welcome comments.
I teach in a very small PN program, and our students get extensive clinical time at a small community hospital. Our grads tend to get work and are successful most of the time, and our NCLEX pass rate has been 100% for the last few years. For education programs, that pass rate is THE gold standard for how a program is evaulated by the BON, and is largely responsible for whether or not a program remains open. (Survey's are also important, but in my state they are once every eight years!) Of course, these new LPN's work in long term care and MD offices, as no local hospitals hire LPN's in acute care settings....and they know they must continue on for their RN to enter the hospital setting. At the RN level, we need fewer "clipboard nurses" in suits and heels and more highly educated nurses at the bedside...but the money is just not there after someone spends the time and $$$ on a BSN or MSN.
Yes they could but the entrance of nursing school acceptance applicants would have to decrease and clinical instructors would need to decrease their student load. I think that this standard would increase retention rate among new to the profession and possibly increase student drop outs to different majors....
I've heard time and time and time again that diploma programs produced the best nurses, yet there aren't any (that I know of) of those programs left. These days, one is barely qualified to breathe without being fully degreed.
Personally, my nursing school experience was one beat above useless, with clinical being nothing more than an early morning waste of time.
And the push to move to only BSN nurses? Don't get me started.
I've heard time and time and time again that diploma programs produced the best nurses, yet there aren't any (that I know of) of those programs left. These days, one is barely qualified to breathe without being fully degreed.
Personally, my nursing school experience was one beat above useless, with clinical being nothing more than an early morning waste of time.
And the push to move to only BSN nurses? Don't get me started.
There are actually 100 diploma programs left nationwide. I graduated from one in 2008 and it is still going strong. And yes, I absolutely feel that my program left me ready to practice.
I've heard time and time and time again that diploma programs produced the best nurses, yet there aren't any (that I know of) of those programs left. These days, one is barely qualified to breathe without being fully degreed.
As far as I know, there are still ~100 diploma programs in the US. Many states have none at all at this point. NC, my state for a long time, still has two. PA, my current state, is a bastion of them; there are three diploma schools just within the healthcare system I work for, and the graduates of the program are v. highly regarded. There are 19, total, in the state.
Interestingly, this topic has been on my mind since I got the latest AJN. The Editorial by Maureen Shawn Kennedy is entitled, "Retaining nurses in the workforce," and there's an article reporting a study on that later on in the issue. However, what struck me as noteworthy was that she begins her piece by saying,
When I graduated from nursing school in 1971 and began my first job, my orientation lasted 3 days and was largely spent in class, learning about benefits and policies and procedures. We were also taught perform CPR and tested on a medication knowledge. When I arrived on the unit where I was to work, a nurse clinician helped me develop my clinical skills. The unit also use the buddy system, wherein new nurses worked alongside more experienced nurses. In working with, and getting to know, the senior staff nurses, I gradually began to feel that I was part of a team.
I think this is relevant to the present discussion, because it speaks to a number of issues that we've sort of been dancing around here. First, she graduated in 1971, and for those of us of similar vintage, we remember those times vividly. The patient who was going to have comparatively minor surgery was admitted ambulatory to the hospital the night before, stayed the hospital for 3 to 7 days afterwards, and if there were 3 IVs on a MedSurg floor of 40 patients, that was remarkable. Yes, really. SCDs, wound VACs, external fixators, specialty beds, and more gadgetry than you can shake a stick at did not yet exist. And really, really sick people did not populate the floors-- they went to ICU, or they died.
Under those conditions, it was understandably fairly easy for new graduate to slide into a work routine. I graduated from a bachelors program at the age of 21, and we had 3 full 8-hour days per week for 3 years of clinical. My first job was in a specialty area. My orientation experience was similar.
Ms. Kennedy goes on to say,
... earlier researchers have shown that, for new nurses, having "support, guidance, timely feedback, supervised training, and continued mentorship" from preceptors is vital to positive transitions.
The article, original research entitled Hearing the voices of newly licensed RNs: the transition to practice, notes in its abstract the objective of the study. "The future of nursing depends on newly licensed RNs who often need help in transitioning from an academic to a clinical setting. This study sought to describe the new nurses orientation experience and to identify ways of enhancing it."
I was struck by the fact that the assumptions in both of these writings include the idea that institutions, e.g., hospitals and other care settings, are assumed to be responsible for the transition and the "comfort" of new nurses during this time. I'm not sure that's a fair assumption. However, it is manifestly true that the hospital setting we graduated into in the 70s and 80s was a vastly simpler system than the one facing new grads today. I have yet to see a change in any nursing education model to account for this.
One of the biggest challenges I see is that due to the increased demands on nurses for professional-level competence in science, mathematics, leadership, and critical thinking skills, it is more difficult to fill our nursing school classes with people who are up to these challenges. I think it comes as no surprise to anyone who peruses the student sections of AllNurses that there are a lot of people in nursing school who are either deficient or incapable of acquiring proficiency in these areas. This means that when they assume a position in a hospital, the hospital has to take up the slack. Perhaps if more nursing schools were even more selective, even more difficult, and demanded considerably more of their students to graduate, the overall product would be of higher quality.
I expect this will provoke howls. Of course nurses are underpaid. Of course we can't necessarily expect our best and brightest young people to enter a field which desperately needs their strengths without offering them more pay and benefits. However, we dig our own graves if we don't pull more better people into our field. If the quality of nursing schools is not up to the task, their graduates aren't up to the task, institutions see that these inadequate practitioners can, in fact, be replaced by UAPs, and there are fewer high-powered nurses to stand up on their hind legs and object.
It's difficult to know where to start. At a time when the BSN is becoming preferred or required for entry level nursing, we are flooded with programs that manifestly cannot produce the same quality that bachelors – level programs produced 30 years ago. In part it's because 30 and 40 years ago young people who went to bachelors programs were unusual. Literally unusual, as at that time only 5 to 10% of nurses in educational programs were in bachelors programs, and fewer in Masters programs. The current accelerated bachelor's programs and the for-profit programs which turn out "masters level" nurses (and their faculties) who don't know the difference between research and Survey Monkey are harmful, really harmful, to our profession. If that's the best we can offer, or if we offer so much of it that it looks like that's what we're about, then perhaps people who make fun of bachelors as a minimum have a point.
There is considerable research that shows that what nursing students, and as a result, new grads, consider to be "skills" are not all there is to successful nursing. While diploma nurses (and I am very familiar with the Brockton Hospital school of nursing, thanks) may graduate with more practice in psychomotor skills, by the end of the first year of practice pretty much all new grads are level in their mastery of these tasks. I mean, how big a part of your day is putting in Foleys and starting IVs? Useful, sure, but is this really what we need to focus on?
Wishing we were all back in the days of diploma grads who could manage a 40 bed ward the day after graduation does not address today's needs, or today's care settings with multiple medications, procedures, assessments, technology, and more that was completely beyond the imagination of the 1970s and 80s. And 90s. We need and must have professionals with stronger academic educational preparation. Colleges of nursing need to be able to provide it. AND hospitals need to provide better clinical nursing practice opportunities for students to learn to integrate it into practice effectively so they can enter practice with a more solid base.
There is no way to teach a nurse experience, only experience begets experience.
One goes to school to develop an educational foundation, then you have to apprentice to gain hands on education.
Unfortunately, nursing as a profession has a weak grasp upon the educational requirements to enter the profession. To contrast this, look at medicine. The physician goes to school and gains a broad educational background. All physicians graduate with a minimum of a MD/DO or other doctorate equivalent. What is the nurse standard of education into the profession? Once graduated the physician has a residency where they gain real world hands-on experience and may follow that up with fellowship.
Once a nurse graduates what does their "residency" look like? A 2 week orientation? 6 month preceptorship? Very few hospitals have structured programs for nurses and fewer have quality programs. Physicians bring money into the hospital while nurses just cost
money. No wonder facilities do not want to invest in nursing.
So are you suggesting that the educational entry requirements for professional nursing be comparable to that of a MD/DO?
Who would that leave on the floor 24/7 with actual patient assignments?
Who would be willing to make that kind of financial investment in education, only to make 30ish dollars an hour?
Or, what facility would be willing to pay a whole gaggle of floor nurses the MD-level salaries such highly educated professionals would surely demand?
So are you suggesting that the educational entry requirements for professional nursing be comparable to that of a MD/DO?
Who would that leave on the floor 24/7 with actual patient assignments?
Who would be willing to make that kind of financial investment in education, only to make 30ish dollars an hour?
Or, what facility would be willing to pay a whole gaggle of floor nurses the MD-level salaries such highly educated professionals would surely demand?
My suggestion is that we have a standardized level of education for entry into the profession with a standardized post-education residency program.
Medical doctors were used as an example because they have a standardized level of education for entry into the profession, they are all doctorate prepared. Whether registered nursing decides to make the ADN or the BSN the standard level of education for entry into the profession is a different discussion, what I suggest is that it be standardized with a standardized post-education residency.
I felt fairly prepared to practice the day I graduated due to the required 250 hours of precepting I'd just completed. Not all schools require such an extensive preceptorship. I'm even more amazed by the way clinicals seem to be conducted now. I liked to make sure the students watching had an understanding of what was going on. I'd ask, "Have you learned about so-and-so yet?" only to find out that they take clinicals before they do the coursework. How does this even make since? Why in the world would you do Maternal Child clinicals in the Spring and then have the class next Fall? Apparently this is becoming the norm, though. I don't understand how this benefits anyone. We would learn about something in the classroom and hopefully see it that week or the next in the hospital.
My suggestion is that we have a standardized level of education for entry into the profession with a standardized post-education residency program.
Medical doctors were used as an example because they have a standardized level of education for entry into the profession, they are all doctorate prepared. Whether registered nursing decides to make the ADN or the BSN the standard level of education for entry into the profession is a different discussion, what I suggest is that it be standardized with a standardized post-education residency.
Ok, that makes a lot of sense. A single educational entry into professional nursing is long overdue. I thought you were suggesting that a doctorate level degree be said entry point....
I wonder what a RN residency would look like? Would it be hospital based? Can the job market support have "attending" RNs overseeing "resident" RNs for periods permutably much longer than a preceptor would traditionally train an orientee?
What nursing really needs to do is figure out if it wants to be a trade or a profession.
The one thing that always baffles me about nursing: I've been involved in various professions in my life and nursing is the only one I've been involved in where some members of the profession actually look down on others with MORE education. I was raised in a culture where education is looked highly upon- people get education for education's sake in order to be a well rounded individual and no one would ever get scoffed at for getting an Ivy league education. Lord, when I started in nursing I was totally blindsided by the way members of the profession would talk smack about people that chose to advance their degrees or go to highly regarded institutions.
Certification, Associates or Bachelor's degree - I think they all make fine nurses. I don't look down on those who chose to pursue routes other than I did and I can't fathom why people are so judgmental towards those that take the University route- BSN, ABSN or ELMSN.
Universities don't graduate practice ready anythings. Most new graduates, regardless of degree still have a learning curve to experience when they enter the workforce. My first degree is a B.A in Psychology: The Ph.D level researchers that were my professors had to actually DO research before they became good at research, the Ph.D level therapists had to DO therapy before they became good at therapy (the hands on portion learned in school doesn't mean the therapist is going to graduate and boom be an awesome totally knowing the ropes therapist) and the Masters level social workers have to have 2000 hours (in some states) supervised practice before they can even write their licensing exam.
The question that needs to be asked then is this: Do nurses want nursing to be a trade or a profession? Doctors, lawyers, accountants, therapists, psychologists, teachers, economists - are professionals and are expected to know the technical and theoretical back ground of their practice. They don't graduate practice ready - there is often orientation periods, mentoring, a period of being a "junior whatever" before they take the lead in their occupation.
On the other hand welders, mechanics, plumbers, carpenters, beauticians and waitresses- the tradespeople- use more physical skill and manual dexterity in order to be proficient in their trade. Many have minimal schooling or learn on the job and get out of their programs ready to go on day 1. However, they don't have to know the in depth science behind what they do. The welder uses heat to put two pieces of metal together (Very simplified description) but he/she doesn't need to know the law of thermodynamics in depth in order to do so.
The problem with nursing isn't graduating practice ready nurses - though I do believe there should be educational and training standards and a standardized entry to practice like the other "professions". It's creating programs and mentorships and methods for new graduate nurses to gain hands on working experience (like residency programs, like internships, like transition to practice programs, like excellent orientation) so they can successfully take their theoretical knowledge and be able to apply it to the technical skills learned in practice.
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trishmsn
127 Posts
I teach in a very small PN program, and our students get extensive clinical time at a small community hospital. Our grads tend to get work and are successful most of the time, and our NCLEX pass rate has been 100% for the last few years. For education programs, that pass rate is THE gold standard for how a program is evaulated by the BON, and is largely responsible for whether or not a program remains open. (Survey's are also important, but in my state they are once every eight years!) Of course, these new LPN's work in long term care and MD offices, as no local hospitals hire LPN's in acute care settings....and they know they must continue on for their RN to enter the hospital setting. At the RN level, we need fewer "clipboard nurses" in suits and heels and more highly educated nurses at the bedside...but the money is just not there after someone spends the time and $$$ on a BSN or MSN.