Crash Course?! Thoughts on RN education

[jjjoy, LPN]

To me, nursing school often felt like a series of crash courses, one in each specialty area. Dozens of disease processes and conditions were covered each lecture, with no time for questions, discussion or digestion.

I can understand the motivation to try to cover so much. RNs currently are hired for nursing jobs as varied as those in NICU, CCU, L&D, invasive procedures, OR, LTC, and more in addition to the stereotypical bedside med/surg nursing position. But is it possible that there's just currently too much material to cover to be adequately prepared for all the potential roles an RN may be asked to fill?

Why have every nursing student cover 1000 pages of L&D nursing (or ICU nursing, pediatric nursing, etc) when most of them will never work L&D (or fill-in-the-blank)? It's great to introduce the students to the broad spectrum of nursing possibilities in case they want to pursue them, but reviewing a 1000-page book of it is a bit of overkill for an "introduction."

And why not focus on symptom assessment and management as opposed structuring nursing texts around 1000 different diseases and conditions? Why have every nursing student study retinal detachment, cervical traction, laryngeal cancer, hydronephrosis....? Cover the biggies such as diabetes, CHF, stroke, etc... and leave the rest for specialty training that's perhaps post-registration. So after one gets their RN, they can take specialty coursework, such as orthopedics, neuro, oncology etc. And it wouldn't take longer because RN training would be much shorter if all students didn't have to cover all specialties as extensively as they do now. And if a nurse wanted to switch specialties, they could take a cram course in just that one area, which would be useful for both the nurse and the employer.

I understand that both nurses and hospitals have benefitted from nursese being able to float between units, but the reality is that after years working in one area, most will forget what they learned about those other areas anyway. As it is, there aren't too many formal ways for a nurse to bone up on their skills and knowledge when changing to a different area. Yes, self-study is important! But for safety reasons, is it really enough to only count on a nurse's training from years prior and their own self assessment of their preparedness to start into a new area?

It seems as if the schools (and BON that set minimum requirements) want nurses to be able to say to just about anything they come across "I studied that in school!" That's a great ideal, but to me, reading 1-2 pages out of thousands of pages of reading doesn't count for much. Having the name of this or that disease sound familiar and having some idea of what body system it affects doesn't really help me take care of a patient. I'll still have to go and look up the condition because I won't remember the details. Meanwhile, because we had to cover so much material in class, we didn't have time to ask questions or discuss things in lecture. We didn't address real world nursing situations - like how we might deal with 6 or more acute care patients or how we might deal with 20+ LTC patients.

Just thoughts! I'm sure there are those who see things differently and have had different experiences. I'm curious to hear any responses!

[Lisa CCU RN, RN]

I see your point. Our program does however prepare us to deal with 6 patients and teaches us time managment.

I think more time should be spent in clinicals...once a week doesn't seem to be enough. Actually, I took a summer ICU clinical, and we had to do two 12's a week and I feel like we learned more there just because we saw the patient two days in a row and saw some progression.

Oh, and I've learned more in my nurse tech positions than in clinicals. One thing that makes that true is the fact we were always waiting for the instructor. I also hated the fact we couldn't do IV pushes without the instructor. I have learned things about IV pushes I never learned in school because the instructor was always there walking us through it.

[sharona97, BSN, RN]

I agree also,it is alot of information and reading and also being able to comprehend. With that said, the human body is so overwhelming just to think from the cellular level to the most obvious, I guess they deem it neccessary no matter how much the info. Good Lecturers help me alot during class time. nothing like a mono tone lecture ugh.

[woody62, RN]

I've been out of basic nursing education for thirty six years. In 2003 I completed two graduate courses in nursing curriculum. Back in 1969 to 1971 I spent twenty four hours a week, two semester's a year, for two years. I had to do all of my reading not only for my nursing courses but also for my three other liberal arts courses, plus labs, plus research papers. Plus I worked full time and helped my parents care for my daughter.

My patients generally were suffering from anything like a CVA to a fractured leg, in traction, to a routine post operative. I also had to know the type of care, likely medications, differential diagnoses, etc. When I did my ICU rotation, we had patients on vents, dialysis, comas, multiple trauma. I am not saying we had to know or do more then todays students but I think you people have it slightly easier. I had no prerequisites. I had only corequistists. I couldn't just concentrate on my nursing courses, I had other course to worry about as well.

I'm sorry but between what I learned about curriculum development in my 2003 classes and my own experiences, you guys need to buckle down. If you think school is tough, what until you get out in the real world. It is really tough.

And if I have insulted anyone, I am sorry.

Wood:balloons:

[jjjoy, LPN]

Woody - I wasn't complaining about the amount of work in nursing school. It just seemed like for the amount of time I had to put into it, I came out of it knowing at little about a lot of things but not enough to really do anything with it. For all of the work it was, I didn't feel I'd mastered anything... except perhaps writing care plans - which no one needs to write as practicing nurses. Yes, you work from them, but you don't have to come up with them from scratch as we did in school. I also learned how to pass the NCLEX.

I expect that there is much to learn on the job, that school won't teach me everything, but I also expect to learn a lot in two years of intensive study (jr/sr year BSN program). We covered a lot of ground but I really didn't feel that I *really learned* much. Maybe that's just an indication of my own strengths, weaknesses and preferences, as I felt the learned the most in my pre-reqs (microbio, chemistry) and auxiliary courses (epidemiology, statistics, psychology).

Some information was repeated again and again through the nursing courses, across the spectrum of of conditions, such as preventing and assessing for DVT and pulmonary embolism, preventing and assessing for skin breakdown, etc.... those things, very important nursing responsibilities, are what stuck. But which medications go exactly with which diseases? What are the prognoses for different diagnoses? What specific symptoms should I be expecting to see? I'd have to look it up same as if it were a disease or condition I'd never formally studied in school. So why spend all of that valuable time studying a multitude of conditions on might come across instead of spending more time in clinical, actually seeing the diseases and conditions?

Sure, I studied a little bit about traction, but if I were to work with a patient in traction, unless I happened to have previous clinical experience with that, I'm going to have to ask for help and look up the details of that specific variety of traction to know exactly what nursing care is required and to understand the specifics of whatever type of traction is being used. If I were to care for patient with AML, I'd have to look up the drugs and information on the disease in order to properly care for the patient; I couldn't just rely on what I'd studied in school.

Going on a tangent here.....

I'm just curious here... wondering what your nursing school experience was like and how it compares to nursing programs today. I don't want to assume one way or another. Did you guys have the same two inch thick texts? Surgical nursing, maternity nursing, etc? Were you assigned hundreds of pages a reading each week in each text? Did you have the same ridiculously vague nursing exam questions? Were lectures essentially a rehash of the readings with no time for questions or elaboration? (Since the texts were essentially already summaries of disease processes and treatments, lectures couldn't really summarize it any more than that). If so, were you satisfied with that?

Some programs today do have strong clinical components but from what I've read here, it seems many do not... often due to liability concerns, I'd imagine, as well as the lack of strong clinical instructors. Students care for no more than 2 patients for much of the time and have to wait around for the instructor to do tasks. Students also often have a hard time coming across enough opportunities to practice skills for all the students. They might have only done one foley catheter and set up a chest tube set once during their entire education.

[time4meRN]

I also agree, I think more time could be spent in clinicals. The real test isn't spitting info back out, it's working in a critical situation and being able to spit it out like it's second nature. To me doing all book work and no experience is like teaching an air line piolet how to fly using only books and very little fly time. Wouldn't want to have him/her fly me anywhere. Much theory can be taught on the job by instructors. When you learn something while you are doing it or it pertains to a task you are doing or have seen, it tend to stay with you. That is a basic rule of adult learning. For instance, If I learn about ABG's in a book I may think , wow that's interesting. But , if I'm caring for a pt with ABG abn's, I have to interpret them with an instuctor,see the pt and assess them, then give the instuctor info on how to correct them, it becomes an experience that makes a new path way in my brain. If I just read it in a book with no experience, it will become part of the endless, info that my brain holds, like locker combinations, addresses etc..

[HealthyRN]

I agree that I graduated feeling like I knew a little bit about a lot of information. It is difficult to retain the information if you don't work in a speciality where you deal with it often. Much of the focus of my education was on passing the NCLEX and becoming competent enough to practice safely. The State Boards of Nursing have decided that all RNs must have certain competencies and knowledge and that is why nursing schools cover the material that they do.

I do think there is a benefit to covering so much material. Even if you don't remember specifics, you should be able to gain at least a basic understanding of certain conditions. It is important to have general knowledge because sometimes you may find yourself caring for someone with a condition that is usually not seen in your speciality. For example, imagine you are working on a burn unit and a 30-week pregnant female is admitted. You may not usually care for pregnant females on the burn unit, but the knowledge that you gained in school should come back with a little reviewing. Imagine how lost you may be if you had never covered pregnancy during nursing school. Granted, you are not probably going to involved with the actual delivery, but you should know something about pregnancy to be able to provide the best care for your patient.

I am now in grad school for FNP and I feel the same way about the material. There is even more material to be covered than in undergrad and even less time is spent on it. However, we are told that the important aspect is to be able to recognize patterns in disease. No matter what level of practitioner you are, you will always have to refer to reference materials to look something up once in awhile. Noone knows everything about the human body, pathophysiology, and the treatment of disease. I am finding that in grad school, it is most helpful to have a strong grasp on the basic physiology. From there, you can better understand the pathophysiology and where things start to go wrong.

[SharonH, RN]

You always have a lot of questions about the status qo and I like that about you. I almost never agree with your conclusions, but nevertheless I really appreciate someone who looks at a situation and questions the value of a certain way of doing things and wonders if there is a better way of doing it.

Now as to this particular post, I can appreciate where you are coming from but here's the thing: I have rarely taken care of a patient who only had diabetes or only had cancer or only had a fractured femur. While you may specialize in one area, you will likely take care of people who have two or disease processes and it is important that you have had at least exposure to the concepts of other diseases.

If you really want to know in-depth about oncology, for instance then you learn the basics of nursing and then you specialize in practice. But you WILL be exposed to other disease processes, even in your specialty.

Your nursing education is meant to prepare you for the basics; entry-level. Unless we return to a situation in which nurses lived and worked in the hospital during their training, there is no remedy for your feeling a lack of preparation for the real world of nursing. It's get exposed to the basics and pick up the rest as you go. I think it's the right way to go about it.

By the way, most students feel to some extent as you do. Have you ever heard the phrase "the more you know, the more you realize what you don't know"? It's true.

[jjjoy, LPN]

It is important to have general knowledge because sometimes you may find yourself caring for someone with a condition that is usually not seen in your speciality.

I agree that nurses should have some basic understanding of a wide variety of conditions. My point was that a 1000 text of maternity nursing seems like more than just an introduction. Of course, it is just an introduction because you're covering a whole multitude of issues and there's no way to get into much depth in just one course. This is the table of contents from one Maternity Nursing textbook (Mosby).

Lesson 1: The Family and Culture (Chapter 1)

Unit Two: Reproductive Years

Lesson 2: Assessment and Health Promotion(Chapter 4)

Lesson 3: Substance Abuse/Violence Against Women (Chapter 4)

Lesson 4: STIs and Other Infections (Chapter 5)

Lesson 5: Reproductive System Concerns: Contraception and Infertility (Chapter 6)

Unit Three: Pregnancy

Lesson 6: Nursing Care During Pregnancy (Chapter 9)

Lesson 7: Maternal Nutrition/Antepartal Fetal Assessment (Chapters 10, 21)

Unit Four: Childbirth

Lesson 8: Nursing Care During Labor and Birth (Chapters 11, 14)

Lesson 9: Management of Discomfort (Chapter 12)

Unit Five: Complications of Childbearing

Lesson 10: Pregnancy at Risk: Gestational Diabetes Mellitus (Chapter 22)

Lesson 11: Pregnancy at Risk: Cardiac Disorders, Lupus (Chapter 22)

Lesson 12: Pregnancy at Risk: Severe Preeclampsia (Chapter 23)

Lesson 13: Pregnancy at Risk: Antepartal Hemorrhagic Disorders (Chapter 23)

Lesson 14: Labor and Birth at Risk (Chapter 24)

Lesson 15: The Newborn at Risk (Chapters 26, 27)

Lesson 16: Perinatal Loss and Grief (Chapter 28)

Lesson 17: Medication Administration

[jjjoy, LPN]

And this is the table of contents for a Med-Surg book (Mosby). It's possible to cover all of the topics in one or two individual courses but not in any kind of depth. One might think this was for an entire year of nursing education.

Section One: Concepts in Nursing Practice

1. Nursing Practice Today

2. Health Disparities

3. Culturally Competent Care

4. Health History and Physical Examination

5. Patient and Family Teaching

6. Older Adults

7. Community-Based Nursing and Home Care

8. Complementary and Alternative Therapies

9. Stress and Stress Management—NEW!

10. Pain

11. Palliative and End-of-Life Care

12. Addictive Behaviors

Section Two: Pathophysiologic Mechanisms of Disease

13. Inflammation and Wound Healing

14. Genetics, Altered Immune Responses, and Transplantation

15. Infection and Human Immunodeficiency Virus Infection--NEW!

16. Cancer

17. Fluid, Electrolyte, and Acid-Base Imbalance

Section Three: Perioperative Care

18. Nursing Management: Preoperative Care

19. Nursing Management: Intraoperative Care

20. Nursing Management: Postoperative Care

Section Four: Problems Related to Altered Sensory Input

21. Nursing Assessment: Visual and Auditory Systems

22. Nursing Management: Visual and Auditory Problems

23. Nursing Assessment: Integumentary System

24. Nursing Management: Integumentary Problems

25. Nursing Management: Burns

Section Five: Problems of Oxygenation: Ventilation

26. Nursing Assessment: Respiratory System

27. Nursing Management: Upper Respiratory Problems

28. Nursing Management: Lower Respiratory Problems

29. Nursing Management: Obstructive Pulmonary Diseases

Section Six: Problems of Oxygenation: Transport

30. Nursing Assessment: Hematologic System

31. Nursing Management: Hematologic Proble

Section Seven: Problems of Oxygenation: Perfusion

32. Nursing Assessment: Cardiovascular System

33. Nursing Management: Hypertension

34. Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome

35. Nursing Management: Heart Failure

36. Nursing Management: Dysrhythmias

37. Nursing Management: Inflammatory and Structural Heart Disorders

38. Nursing Management: Vascular Disorders

Section Eight: Problems of Ingestion, Digestion, Absorption, and Elimination

39. Nursing Assessment: Gastrointestinal System

40. Nursing Management: Nutritional Problems

41. Nursing Management: Obesity—NEW!

42. Nursing Management: Upper Gastrointestinal Problems

43. Nursing Management: Lower Gastrointestinal Problems

44. Nursing Management: Liver, Pancreas, and Biliary Problems

Section Nine: Problems of Urinary Function

45. Nursing Assessment: Urinary System

46. Nursing Management: Renal and Urologic Problems

47. Nursing Mgmt.: Acute Renal Failure and Chronic Kidney Disease

Section Ten: Problems Related to Regulatory and Reproductive Mechanisms

48. Nursing Assessment: Endocrine System

49. Nursing Management: Diabetes Mellitus

50. Nursing Management: Endocrine Problems

51. Nursing Assessment: Reproductive System

52. Nursing Management: Breast Disorders

53. Nursing Management: Sexually Transmitted Diseases

54. Nursing Management: Female Reproductive Problems

55. Nursing Management: Male Reproductive Problem

Section Eleven: Problems Related to Movement and Coordination

56. Nursing Assessment: Nervous System

57. Nursing Management: Acute Intracranial Problems

58. Nursing Management: Stroke

59. Nursing Management: Chronic Neurologic Problems

60. Nursing Management: Alzheimer’s Disease and Dementia

61. Nursing Management: Peripheral Nerve and Spinal Cord Problems

62. Nursing Assessment: Musculoskeletal System

63. Nursing Management: Musculoskeletal Trauma and Orthopedic Surgery

64. Nursing Management: Musculoskeletal Problems

65. Nursing Management: Arthritis and Connective Tissue Diseases

Section Twelve: Nursing Care in Specialized Settings

66. Nursing Management: Critical Care

67. Nursing Management: Shock, SIRS, and Multiple Organ Dysfunction Syndrome

68. Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome

69. Nursing Management: Emergency and Disaster Nursing

[sharona97, BSN, RN]

I agree with you SharonHRN as to thee amount of clinical skill opportunities: however, I saw many students who preferred to stay aback. I myself was very assertive during clinicals and often volnteered. There is some stock to that part of the quotian. I also beleive the profession we are in will always require us to continue our knowledge in our scope of practice in spite of the state by-laws. So true to think about what you don't know.

[sharona97, BSN, RN]

I see your point JJoy, yet I also see an opportunity for references when needed.