Concerns with safety after orienting a foreign graduated nurse

Specialties Geriatric

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Specializes in LTC, Med-surg.

I am working as a registered nurse in a long-term care facility with short-term rehabilitation services. I work PRN while I am attending graduate school and mostly work in the short-term rehab unit. I oriented a foreign-graduate nurse from India who I feel is not safe. On her first day, I asked her aspects of her education, I wanted to know what she already knew and what I can work with to help speed up her knowledge. I came to find out that nursing in India is very skill-based which includes inserting IVs, urinary catheters, applying oxygen, administering medications (but without knowledge of the medications' actions...only the doctor knows the medical knowledge). I was asking her questions about medications and she seemed to know only the blood pressure medications or heart medications. I asked her if she took any pharmacology course in India or here to prepare for passing the NCLEX-RN and she said she did not need to take a course like that to apply to challenge the exam. She admitted she only studied the medications that she knew will show up on the exam based on her preparation materials. She also added she has been trying to clear the NCLEX-RN or NCLEX-PN exam since 2014. She doesn't understand basic anatomy, physiology, pathophysiology, and dose concentration. Her technical skills are also lacking and she struggles to complete dressing changes, IV medications, etc but that can be learned. Skills are just hands-on exposure but I can't tolerate that she doesn't have the medical foundation to do this job. She doesn't know pathophysiology and that scares me. I just feel like she is a medication tech which is not what her role is clearing the NCLEX-RN exam. I have yet to see her complete a physical exam but I am doubtless she can complete it well since she has told me she did not need to do a hands-on competence course to evaluate her technical skills. Moreover, she has voiced she does not assess patients as her duty as a nurse in India since she mainly gets the doctor when the patient looks toxic. I have raised these concerns to the ADON and DON. I have told them that this nurse does not understand medications and that she is unsafe. I am scared for my patients. I am scared that in her role as a skilled-based healthcare worker she will not know when the patient is deteriorating. She will not voice her concerns to the doctor because she is not familiar with the clinical picture of the patient and maybe even uncomfortable being assertive to advocate for her patients. Today, I asked her what is swelling in the legs would be called, she did not know "edema." I just can't imagine that they have lowered the standards to the NCLEX-RN because of a pandemic. I suggested that she try the night shift because it was a slower pace and she would have time to understand aspects of nursing but she was not willing to do that. I guess if someone has experienced this, let me know what you think..

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Do you have to fill out and or sign a competency evaluation on her or any other information concerning her job performance? If she actually harms a patient then as a mandated reporter you have the legal duty to report that to the authorities which includes law enforcement and to the nursing boards. 

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I'm not sure you remember being new, and might be really overestimating how many meds any new graduate is going to remember.  That's why books and Google exists.  Especially because VERY FEW physicians can just name off the action of a drug, unless it's something in their specialty, but you're expecting that from a new graduate nurse.

And not everyone is going to know all the terminology.  I'd say that in over 10 years of working in healthcare, I've almost always heard edema just called "swelling," or "swollen."

You're focusing on the wrong things.  Does she know how to find out what she needs to know about the drugs?  Actually see if she can do an assessment and find things wrong.  Have her assess a patient that you think the doctor needs to be involved and see what she thinks.

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Specializes in ER.

Write a letter to your supervisor detailing your concerns. If they keep her on, you’ve had your say.

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Specializes in oncology.

 

On 10/5/2020 at 8:02 AM, strawberryluv said:

I oriented a foreign-graduate nurse from India who I feel is not safe.

What exactly was your role? What were the expectations you had for your role?

On 10/5/2020 at 8:02 AM, strawberryluv said:

Her technical skills are also lacking and she struggles to complete dressing changes, IV medications, etc but that can be learned.

Health Assessment (including physical assessment), pharmacology, and pathophysiology are integrated in many curriculums and not specific courses. Also most new graduates have not done any communications with physicians about a concern prior to graduating. 

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what I can work with to help speed up her knowledge

This is a wonderful thing for you to assist her on. I hope you can see your way to continue to help her acclimate and learn in our country. 

 

If she passed NCLEX, she has met the minimal competence standard for a license in your state and I am not sure it is your role to assess her knowledge and competence level. There are alot of staff nurses I have met through my career that I was unsure of the exact level of their knowledge base. If I saw something was unsafe I had an obligation to report it but even though I have taught nursing for 40+ years, I did not feel I should interrogate a nurse on what constituted her education.

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Specializes in LTC, Med-surg.
On 10/6/2020 at 7:37 AM, Amanda Rain said:

Do you have to fill out and or sign a competency evaluation on her or any other information concerning her job performance? If she actually harms a patient then as a mandated reporter you have the legal duty to report that to the authorities which includes law enforcement and to the nursing boards. 

Nope. I do not need to do that but I am asked how the nurse is doing by my management and I told them the truth

On 10/6/2020 at 10:52 AM, TheDudeWithTheBigDog said:

I'm not sure you remember being new, and might be really overestimating how many meds any new graduate is going to remember.  That's why books and Google exists.  Especially because VERY FEW physicians can just name off the action of a drug, unless it's something in their specialty, but you're expecting that from a new graduate nurse.

And not everyone is going to know all the terminology.  I'd say that in over 10 years of working in healthcare, I've almost always heard edema just called "swelling," or "swollen."

You're focusing on the wrong things.  Does she know how to find out what she needs to know about the drugs?  Actually see if she can do an assessment and find things wrong.  Have her assess a patient that you think the doctor needs to be involved and see what she thinks.

I didn't have a chance to do this. Anyway, what I was told by colleagues was she couldn't handle the workload at the unit and resigned after 1 month..

 

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Specializes in LTC, Med-surg.
On 12/5/2020 at 6:20 PM, londonflo said:

 

What exactly was your role? What were the expectations you had for your role?

Health Assessment (including physical assessment), pharmacology, and pathophysiology are integrated in many curriculums and not specific courses. Also most new graduates have not done any communications with physicians about a concern prior to graduating. 

This is a wonderful thing for you to assist her on. I hope you can see your way to continue to help her acclimate and learn in our country. 

 

If she passed NCLEX, she has met the minimal competence standard for a license in your state and I am not sure it is your role to assess her knowledge and competence level. There are alot of staff nurses I have met through my career that I was unsure of the exact level of their knowledge base. If I saw something was unsafe I had an obligation to report it but even though I have taught nursing for 40+ years, I did not feel I should interrogate a nurse on what constituted her education.

Answering questions on a multiple-choice exam does not mean someone is minimally competent. A test is a test. Reality is something different.

My role was to orient her on my unit and show her where things are, the flow of the unit, documentation, how to utilize resources as a nurse on the unit, etc

I never asked her if she took any courses for these subjects but I asked her if she was familiar with health assessment, pathophysiology, anatomy from her nursing school days. She indicated she did not study these subjects.

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Specializes in oncology.
21 minutes ago, strawberryluv said:

Answering questions on a multiple-choice exam does not mean someone is minimally competent

What you're feeling and saying has been voiced since the first multiple choice test to license nurses was created. (Before that it was an essay test in my state--way before my time!) Then it was a 2 day multiple choice test given twice a year in a large convention-center type building. It took 3 months to get results. Currently candidates perform a computerized adaptive test which allows graduates to test year round and a determination of satisfactory knowledge base takes a couple hours.

I appreciate your feelings about the determination of competency. However all states are members of The National Council State Board of Nursing and use a graduation from a state approved professional nursing school (or evaluation of a transcript from a foreign school) and the successful completion of the NCLEX as satisfactory competence. What would you suggest would be a better wayof determining safety and competence? Every 3 years the NCSBN does a thorough investigation of what today's nurses need to know and that content goes into the test bank. Sometimes the pass rates change dramatically. When there are significant changes you can see that 4th year dip in scores when looking over several years. 

As it turns out the nurse did realize this was not the job for her.

You mentioned you are in graduate school. May I ask what specialization? If you are focusing on a nursing education role, you will have input in curriculums and hear how the NCLEX is created and utilized in testing a new graduate (or new nurse to the US). I truly would love to hear your ideas.

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