Crash Course?! Thoughts on RN education

[jjjoy]

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!

[deeDawntee, RN]

My take on nursing school is a little different. I see nursing school as a series of hurdles designed to weed people out. They want to see if you can study material, retain it and test well on it. They want to see if you can follow protocols down to the last detail (like bed-making and hand-washing). They want to see if you can handle criticism, non-defensively, make the changes necessary and not fall apart in the meantime. Can you spend all the hours it takes to prepare care plans in the proper wording etc, know your medications and interact with patients in a way that shows the potential good bedside-skills.

They want the people out of their programs that are likely not to pass NCLEX, since the existence of their program is dependent, to some degree, on the passing rate of their graduates.

I think when you graduate from nursing school and have passed NCLEX you have cleared a thousand different hurdles. Now you can go out there and learn to be a nurse. Hopefully, because you were able to make it through, you have the brains and potential to pick the rest of it up in your orientation period and in that first all-important year. It probably does all work out in the long run, but it isn't a very comfortable process for the nurse!! It is a tough row to hoe!

[Ariesbsn]

fronky bean,

I have a BSN. My school lumped Peds and OB together into one course. I had a whopping 5 days of clinicals (30 hours total). Of those 5 days, I had 2 experiences to try and feel a fundus. I wouldn't know the feel of a fundus from the feel of Adam's house cat. I would never have taken a fresh post partum patient when I worked in ICU. I don't know enough to even come close to providing safe care.

[jjjoy, LPN]

My take on nursing school is a little different. I see nursing school as a series of hurdles designed to weed people out... I think when you graduate from nursing school and have passed NCLEX you have cleared a thousand different hurdles. Now you can go out there and learn to be a nurse.

I agree that nursing school does sometimes function as a weeder and I think some weeding out is reasonable.

I suppose my contention in this thread is with the second half of your statement... "now you can go out there and learn to be a nurse." Because when you graduate you ARE a full-fledged RN, not a junior RN or a probationary RN or the like. And in some places, the new nurse is given a full-load with full responsibilities in just a few months (sometimes after just a few shifts such as in some LTC facilities).

There is still a fairly pervasive assumption even among nurses, that anyone who is an RN should be able to handle acute care. Many experienced nurses and hiring personnel out there expect nurses to be farther along on their learning trajectory than many new grads are. And new grads are too often criticized whether openly or through inference and body language, that they ought to know more, be faster, etc.

If the RN is truly more of a license to learn (and then practice) as opposed to a license to practice what has already been learned (in school, not discounting the fact that one must continually be learning beyond formal education), then maybe the different kinds of nurses should be more formally acknowledged. I can imagine some kind of unique nurse classification for nurses who have 'proven' their skills in an area of nursing. Once the newbie has 'survived' for a certain amount of work hours (such as the equivalent of year of full-time work), then the nurse moves from being *just* an RN, to an official "ACRN" Acute Care RN, or whatever labelling that formally distinguishes RNs who haven't 'proven' their bedside skills from those who have. Some RNs might never become ACRNs (or whatever) if they never chose or try to work in acute care. And thus, any RN coming into acute care as *just* an RN won't be expected to be "up to speed" or to "hit the ground running" or the like. Of course, those RNs with extra skills or talent would be fully functioning sooner than others, but just as with school, all would have to put in XX amount of hours to move up in status to ACRN (or whatever you might call it).

This is how it tends to work informally now. The new grad needs that "at least one year of med-surg under their belt to hone their skills" ... and if they don't for whatever reason some nurses don't consider them to be "real" nurses. So with some kind of official ACRN status, nurses could talk about being an ACRN or some other kind of RN (PHN, school nurse, occ health nurse, etc).

Again, just thoughts... :chair::monkeydance:

[kcalohagirl]

I may need to read the entire thread when I am a little less brain-dead. (It has been an insane week so far, and it is not over yet!)

Initial thoughts. . . . .

I can't comment on other nursing programs, as I only attended mine. However, I believe here in the US, we are generally educated as "generalists". We know a little about a lotta stuff. In my program, we did a "Basics" course, (bed baths, bed making, assessments, and the basics of meds). Followed by "med-surg", then either psyche or ob or peds. During senior year we started with either critical care or leadership (during which we began to take a full load of patients on a floor, usually 4-5) oh, and I almost forgot "community nursing", followed by "capstone" which was basically a preceptorship, where we moved into the RN role.

We had the most "hands on" time in the basics, med surg, icu, and leadership settings. I think the philosophy of our program was that most nurses move into these roles initially. Clinical time in OB and Peds was quite limited. This was explained to us as these areas being "specialties" that the majority of the graduates would not enter. We still had some great experiences in both peds and ob, but we rotated through clinics, support groups for teen mothers, etc. not just the hospital setting. From talking to other people who graduated from different programs, I think we got a much broader look at those specialties.

I can't say specifically, but I believe in some other countries, (the UK, I believe) nurses choose their specialty in university. Although I think that may provide for a broader education in that area, I am really glad that I didn't have to make a decision about my specialty before graduation. I took a job because it was a great opportunity, not realizing that I was finding my passion in the process. I would never have chosen the route I did had I been asked initially.

[fronkey bean]

I'm puzzled by your characterization of diploma programs. When I graduated from a hospital-based diploma program in the mid-'80s, I graduated prepared to "hit the ground running" and practice as a Registered Nurse from day one, which I can certainly not say for graduates today. I don't understand what is meant by being prepared to be "very competent in one area" -- my school prided itself on the fact that its graduates could be dropped down anywhere nursing was happening, and we could do the job. As for "progressional" education, I got a much better education in critical thinking & problem solving, managment, ethics, legal issues, professionalism, etc., in my original diploma program than I did in the BSN completion program I later attended, or the new graduates I encounter these days have gotten. The school encouraged us from day one to consider the diploma a starting point, not a terminal degree, and to plan on continuing our education beyond basic licensure. Many of my classmates (and myself) have gone on to take graduate degrees and practice in a wide variety of advanced practice roles and specialty areas. Frankly, the longer I've been out of nursing school and the more I've seen, the more I appreciate what an excellent nursing education I got. I've taught in ADN and BSN programs since then, and am shocked at how little nursing students learn about nursing now, compared to what we learned back in the "bad old days" that everyone in nursing loves to badmouth now.

I find it extremely ironic that, as time passes, the more there is to know in nursing, and the more accountability and responsibility nurses bear in their practices, the less we are teaching nursing students. One of Florence Nightingale's main contributions to nursing was to establish it as an academic discipline, to be taught in educational settings instead of through "on the job training" -- and yet, for the last couple decades or so, we've been teaching less and less nursing to students and are, more or less, reverting back to OTJ training. (Nursing administrators and educators in hospitals will tell you openly that they don't expect new grads to know anything about nursing -- they expect to have to teach them everything they need to know to function on a floor.) There are many areas in which I feel the larger nursing community has "thrown the baby out with the bathwater," and nursing education is certainly one of them.

No insult intended to diploma nurses. What I meant was they were designed to train you to be a bedside nurse and, while you may hve received great management, research, case management skills, etc. from your program that is not generally true. In addition, I think any nurse that works at the bedside long enough will pick up a lot of knowledge. There are great backyard mechanics who have been taught to work on cars by other backyard mechanics who can keep a car running that no-one thought had a prayer of cranking. Then there are mechanics who have received hours of special training and instruction on how to work on various engine parts and have been certified as experts. They both know how to work on a car but I know which one I want working on my porshe (If I had a Porshe that is).

That sounds stuck up and I don't mean it to, but I really do think that the more education a nurse has the better nurse s/he will be in the long run, even if they are a little clumsy w/ proceedures for a little while.

fronky bean,

I have a BSN. My school lumped Peds and OB together into one course. I had a whopping 5 days of clinicals (30 hours total). Of those 5 days, I had 2 experiences to try and feel a fundus. I wouldn't know the feel of a fundus from the feel of Adam's house cat. I would never have taken a fresh post partum patient when I worked in ICU. I don't know enough to even come close to providing safe care.

What can I say, you had a horrible peds/ob experience.

[jjjoy, LPN]

What can I say, you had a horrible peds/ob experience.

This seems to be a big problem in the whole BSN/ADN/diploma mess. Both have to meet the minimum for accreditation but beyond that the content of all the various programs varies widely such that one can't tell from the degree the person holds what kind of training they've had.

But the original topic is RN education in general. I'm wondering if it would be more important for the nursing students to prove that they can look up and utilize information than to have them try to cover, even if just cursorily, just about every condition they might come across. I can see the point that having studied at one time, the next time you come across it it makes sense more quickly. But on such a basic level, it's not about making sense, it's just about memorizing. And the reality is that nursing students don't memorize every last thing out of those big texts. You have to pick and choose what to focus on. So why not focus more thoroughly on the conditions that nurses are most likely to see instead of making it seem that the student should know every last detail of every last disease covered? Why not have class time be utilized to interact and discuss situations nurses come across and the kind of choices and judgments they will have to make instead of having a lecturer rush through dozens of conditions so that they can say it was 'taught' even though there was no time for discussion, questions, or practical application?

I'm sure some schools and instructors out there are better at presenting their material and doing more than just rehashing the text, but from what I've read here, it sounds like my program wasn't an exception.

[Altra, BSN, RN]

Interesting. After spending my first 2 years in nursing in a large teaching hospital, and learning right alongside interns and residents, I am of the opinion that the trend toward extended orientations/preceptorships/nurse residencies/whatever label you wish to use should absolutely continue. Instead of focusing on how much can be crammed into basic nursing education and whether or not it's "enough", why not recognize the reality that clinical practice is developed over time? No one would dream of turning an intern who passed the medical licensing exam 6 weeks ago loose on 6 or more patients without supervision -- why is it exactly that this is expected of new nurses?

I would also like to say that I whole-heartedly agree w/elkpark's post above re: diploma programs. My diploma school experience reflects much of what was stated in that post, even though our respective diploma experiences took place 2 decades apart.

[jjjoy, LPN]

I am of the opinion that the trend toward extended orientations/preceptorships/nurse residencies/whatever label you wish to use should absolutely continue.

I agree that such programs are a benefit and should be encouraged.

[pagandeva2000, LPN]

I also thought that I walked away with too little skills and too much information. I didn't have much clinical time in school, maybe one or two days a week, and most of the time, it was not for the entire shift. I was very nervous to work in med-surg because of that.

[SuesquatchRN, BSN, RN]

I also thought that I walked away with too little skills and too much information. I didn't have much clinical time in school, maybe one or two days a week, and most of the time, it was not for the entire shift. I was very nervous to work in med-surg because of that.

My clinicals were a joke.

I completely agree with this.

[pagandeva2000, LPN]

My clinicals were a joke.

I completely agree with this.

I think my clinical experience was such a waste of time that I was glad when the instructors used to cancel out as much as they did. I used that time to study what would be on the next exam and NCLEX. In most cases, clinicals did not prepare a nurse in my opinion because they do not prepare you for dealing with a real load of patients independently because the student is either babysat or just placed on their own with one or two patients (if the clinical instructor is exceptionally lazy). I really could have done without them.

[sharona97, BSN, RN]

Well that's scary to hear that some clinicals were cancelled. What did they have a dentist appt or something? Our program has clinicals QWEEKEND BETWEEN 3 SITES,then also 2 days during the week closer at the end of the program.

Does the NCLEX focus more on theory then or do they have random equal amounts of questions on clinical application? Just curious.

Thanks.