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!
Great post -- However, I can tell you, as a nurse educator, that it is the hospitals serving as clinical sites that refuse to allow students to do invasive procedures because of liability concerns, not the schools and clinical instructors.
Wow, that's interesting. I have never come across a hospital that limited the students. Usually it is faculty related as the students are practicing under the instructors license. Or it is because there are too many students and the instructor only has one body, making it difficult to get all the students involved in doing procedures. I would have to go to my admin if a hospital I worked in was the problem. How do they expect students to learn anything if they aren't allowed to do anything? It doesn't matter how much confidence you have, the patients can always figure out if you have performed a procedure before or not. Is it non-teaching hospitals (ones without residents,etc.) that are more likely to limit the nursing students learning experiences?
Shellsincanada - I appreciate your wanting to address the issue of BSN and ADN/diploma training. There are many other threads dedicated specifically to that issue, so I hope we can keep this thread on RN education in general.
Sorry I had to respond to the statement in which an a diploma was considered to be the same as a backyard mechanic. I am quite stunned by the analogy that diploma nurses don't HAVE an education. I suppose I should stay out of this thread until I get the "proper" education.
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.
Would it be possible to get a class list/ course list of that this type of program offered?
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.
Yes,
It's LONG past time for an RN internship/residency "year" like new physician resident.
I graduated from a diploma nursing school in 1971, and felt very comfortable after graduation, immediately taking 3-11 charge on a peds unit. The first day in school we were on the floor making beds, no joke. We spent 3 months in rotation in each specialty. In a period of 2 weeks I assisted with 13 cholecystectomies (when patients were opened up--no such thing as laps then). By the end of that 2 weeks I could have done one by myself. So it goes with OB, orthopedics, pediatrics, etc. By our junior year we were doing charge, so things have changed so much. We would attend classes in the morning or afternoon and spend the remainder of the time with patient care. No, the books weren't the tomes everyone has today.
There should be a better way to provide students with more patient care to gain the experience necessary to make the adjustment. By the way we did have a mini class called "Professional Adjustment" that covered many tools that would be needed, such as ethics, etc.
I completed my BSN 16 years later, and am working on the masters now. I continue to learn new things everyday and love my work. May you find the joy in nursing that I have.
As nurses, we don't diagnose. Outside of the ED or patients who are in specifically because their condition needs special diagnostic procedures, most nurses' patients will already have diagnoses assigned by the MD. There are also certain common conditions that nurses should well-trained in such as COPD, diabetes, acute coronary syndrome, since so many patients will have these as comorbidities as well as primary conditions. I can see giving nursing students exposure to all of the wide assortment of conditions they may come across,... but I don't see that those would need to part of the core content to be mastered.
To be minimially functional, the nurses needs to recognize when something is wrong, what the nurse can do independently to address the situation and when they need to bring other health personnel to help with the situation. After time, nurses WILL be able to second-guess the MD if something new comes up, but fresh out of school, new nurses shouldn't be expected to have that ability, should they?
Also, there are certain telltale symptoms that nurses should be aware of such as that of appendicitis, MI, etc. But to minimally functional, it would seem that what's most important is that the nurse recognize when a patient is deterioriating (shortness of breath, cyanosis, decreased LOC, diaphoresis, etc) and to take appropriate measures (administer oxygen, pain medicine, encourage fluids, etc) and to contact other health personnel when necessary (the MD, RT, etc). There is also all of the ongoing nursing care that helps prevent complications and promotes patient comfort and well-being.
If the nurse has a good, basic understanding of physio, pathophys, pharmacology, etc, then all they need to do is look up the diagnosed condition and put the pieces together in terms of presenting symptoms, treatments being ordered, potential problems, etc. The *nursing* care for shortness of breath, postoperative pain, etc is the same no matter the etiology, though, of course, the medical treatment (eg administered meds) might be different. The nurse will assess, determine what nursing needs the patient has, plan and give that care and evaluate (ADPIE). The new nurse will need to frequently access reference materials and colleagues' feedback in this process until their experience is such that they can quickly and automatically run through that process, mentally checking that the prescribed meds are appropriate, which complications are most likely, etc.
Yes, the nurse should understand the difference of the underlying conditions, and the nurse will - even without specific training in that condition in nursing school, because he/she will have a good grasp of pathophys and will use their training from nursing school to find out what they need to know to give good care for that condition.
I think there is no such thing as "minimally functional" in nursing. I do not want a minimally functioning nurse to take care of me. You need to know enough right from the moment you're off orientation to know what questions to ask. Also, while I don't dx, I do recognize medical conditions and need to know the precise info to give a doc to get the right order. Yeah, sometimes "I just feel like there is something wrong" is all you can tell a doc but that should definitely be a rare statement. And I would sure hate to be stuck researching a condition while my pt is in distress and I don't know what to tell the doc.
Your analogy doesn't really work here. So do you think diploma nurses are the "backyard mechanics"? Or the bsn nurses? The BSN students have the theory but not as much clinical are you saying that they will be the nurses are more likely to learn while just hanging around at the bedside like the backyard mechanics?
Here's a question- with your imaginary porshe- who do you want taking it apart? a person who has read about it in a book- but hasn't actually worked on a car ?
My education was 20 months long- with BOTH lots of clinical and theory , compared to a bsn of 24 months, with much much less clinical. I didn't just hang out at the beside and learn from other backyard mechanic nurses. I am not sure you understand what most ADN, or diploma programs are about. You do realize we actually go to school and it isn't just on the job training.
Shells, sorry. Honestly no insult was intended, JMHO. I didn't mean to get us off topic. Mabey we can discuss it further in another thread.:icon_hug:
I think there is no such thing as "minimally functional" in nursing. I do not want a minimally functioning nurse to take care of me. You need to know enough right from the moment you're off orientation to know what questions to ask. Also, while I don't dx, I do recognize medical conditions and need to know the precise info to give a doc to get the right order. Yeah, sometimes "I just feel like there is something wrong" is all you can tell a doc but that should definitely be a rare statement. And I would sure hate to be stuck researching a condition while my pt is in distress and I don't know what to tell the doc.
I see your point. At what point did you feel you had enough knowledge and experience to be able to quickly recognize specific medical conditions and to know the precise info to give a doc to get the right order? Was your nursing school program one of the more clinically intense programs that had you taking on the kind of responsibilities that working nurses have? Have you had the opportunity to work with recent new grads from different programs? Do you think they are ready to for the job? By accrediting the schools and granting licenses, the BON has deemed all new grads as "ready" to start work as nurses.
In my experience, many new grads don't graduate "ready to hit the floor running" - it takes time and experience to get to that point, and many clinical programs don't come close to approximating the kind of experience a nurse needs to be more than just minimally functional in an acute care setting. Also, not everyone can be the best - 10% of all graduates in any field were in the bottom 10% of the class.
Graduation and licensing is considered legally to be minimally functional, isn't it? Yet many nurses concur that it can take up to a year for a nurse to feel competent. Meanwhile, new nurses aren't quite sure if they're doing good enough and often feel like their care is inferior. They take solace in the fact that they graduated nursing school, passed the NCLEX and haven't been fired... that these things must mean that they safe enough, even though they may not feel as competent as they'd like.
If there weren't such a huge demand for nurses, I'd be more accepting of a 'sink or swim' mentality and of training programs that focus more on weeding out the weak versus training up those who aren't as strong as the best of the best. And please don't take that to mean that I think everone should just be passed along regardless of capability. I just think more can be done in school to create graduates who will be successful and confident in the profession.
Wow, that's interesting. I have never come across a hospital that limited the students. Usually it is faculty related as the students are practicing under the instructors license. Or it is because there are too many students and the instructor only has one body, making it difficult to get all the students involved in doing procedures. I would have to go to my admin if a hospital I worked in was the problem. How do they expect students to learn anything if they aren't allowed to do anything? It doesn't matter how much confidence you have, the patients can always figure out if you have performed a procedure before or not. Is it non-teaching hospitals (ones without residents,etc.) that are more likely to limit the nursing students learning experiences?
I agree with Elkpark that it is usually the facilities that are limiting the student's ability to perform procedures and it is not just the non-teaching hospitals. I did my clinicals in a large university hospital and there were certain procedures, like IVPs and NG tube insertions, that we were not allowed to perform. In my peds and psych rotations, we were not allowed to pass any meds. Sometimes it was instructor-related, as in the instructor was so busy that she was unable to supervise a procedure, but usually staff nurses were accomodating for this.
I believe that more clinical time would be valuable for RN education, but in the end, anyone can learn skills. I don't believe that my career has suffered at all because I did not perform any phlebotomy or IV sticks when I was in nursing school. I started in the ED right out of school and I could stick almost anyone after 3 months. Nursing is more than just skills.
I believe that more clinical time would be valuable for RN education, but in the end, anyone can learn skills. I don't believe that my career has suffered at all because I did not perform any phlebotomy or IV sticks when I was in nursing school. I started in the ED right out of school and I could stick almost anyone after 3 months. Nursing is more than just skills.
Clinical time and experience isn't just about the manual skills but also about seeing and recognizing a variety of different symptoms and diseases in a variety of different patients. Clinical time and experience is about being on the floor enough to have exposure to changes in patient status, to become familiar with what a patient "going bad" might look like. Also, a new nurse needn't be proficient in all manual skills, as they can be easily learned, but if a new nurse isn't proficient in MANY tasks, they will be frequently having to stop and getting even further behind in their work as they are learning a bunch of other things as well.
In my program, we only had focused exposure to our own individual assisgnments - 2 to 4 patients/week. Since all of us students were on the same floor, we couldn't very well all flock around the best learning opportunities. One nurse might have had 3 different student nurses working with their patients, so they couldn't just let you tag along for everything they were doing. And if we disappeared off to other patients that we weren't assigned to, there was the threat of the instructor accusing the student of putting themselves (and their learning experience) before their patients. We had only a few shifts where we were assigned specifically to one nurse and assisted with all of their patients - and that was part of our ICU rotation.
A new grad is learning all the floor policies, struggling with how to prioritize so many different changing needs, just beginning to hone their assessment skills, just starting to match textbook descriptions and explanations to real work situations (oh, THAT'S what mild dyspnea looks/sounds like) and more, all at the same time. If school doesn't give the opportunity to learn these things, then they must be learned on the job. But on the job, a new nurse if often expected to be able to "pull it all together" in just a few weeks (6-12 weeks - which can translate in to only a couple of dozen shifts).
Clinical time and experience isn't just about the manual skills but also about seeing and recognizing a variety of different symptoms and diseases in a variety of different patients. Clinical time and experience is about being on the floor enough to have exposure to changes in patient status, to become familiar with what a patient "going bad" might look like. Also, a new nurse needn't be proficient in all manual skills, as they can be easily learned, but if a new nurse isn't proficient in MANY tasks, they will be frequently having to stop and getting even further behind in their work as they are learning a bunch of other things as well.
In my program, we only had focused exposure to our own individual assisgnments - 2 to 4 patients/week. Since all of us students were on the same floor, we couldn't very well all flock around the best learning opportunities. One nurse might have had 3 different student nurses working with their patients, so they couldn't just let you tag along for everything they were doing. And if we disappeared off to other patients that we weren't assigned to, there was the threat of the instructor accusing the student of putting themselves (and their learning experience) before their patients. We had only a few shifts where we were assigned specifically to one nurse and assisted with all of their patients - and that was part of our ICU rotation.
A new grad is learning all the floor policies, struggling with how to prioritize so many different changing needs, just beginning to hone their assessment skills, just starting to match textbook descriptions and explanations to real work situations (oh, THAT'S what mild dyspnea looks/sounds like) and more, all at the same time. If school doesn't give the opportunity to learn these things, then they must be learned on the job. But on the job, a new nurse if often expected to be able to "pull it all together" in just a few weeks (6-12 weeks - which can translate in to only a couple of dozen shifts).
I agree that clinical time isn't just about skills, but also about exposure to patients and a variety of disorders. I felt that I learned the most in my clinicals during my critcal care preceptorship, where I was assigned to one nurse and took on nearly a full patient load. It would have been nice to have had more clinicals like that. However, the other clinicals were spent learning the basics, such as safety, assessment skills, med administration, how to look up information, etc. Would I have felt prepared for that clinical without the preparation of the others? I do feel that they certainly could have moved along more quickly. Perhaps just the first year of clinicals in my BSN program should have been dedicated to the basics and beginning in the junior year, students could take on the RN role more fully. However, this would require a lot of staff nurses willing to take on a lot of liability to serve as preceptors with little or no compensation. I would be willing to do that for a student but many nurses may not feel comfortable with that role.
I think most ... well I would say hospitals but it's not something that upper management really cares about I think... Okay most experienced nurses that work in units that hire new grads, realize that the whole first year is an internship. It does take time to match clinical theory with experience. It doesn't take that long to figure out how to organize a shift, give report, chart, etc. But it does take about a year to be comfortable and somewhat competent.
Now, the gap is in the actual working conditions that most USA nurses encouter. Three months orientation is considered decent, provided your preceptor acts like a real preceptor. Six months is considered good for ICU and ER and I believe our local hospital has nine months for OR positions. Lovely. And yes, they are hiring new grads into PACU now, I don't know what their orientation period is.
I think the reason internships aren't extended is expense. The people that make a profit off running hospitals don't see the need to staff in such a way that new nurses get better initial training. Heck, unless it's legislated, they don't see the need to staff beyond "wartime triage" type numbers.
RN1989
1,348 Posts
Wow, that's interesting. I have never come across a hospital that limited the students. Usually it is faculty related as the students are practicing under the instructors license. Or it is because there are too many students and the instructor only has one body, making it difficult to get all the students involved in doing procedures. I would have to go to my admin if a hospital I worked in was the problem. How do they expect students to learn anything if they aren't allowed to do anything? It doesn't matter how much confidence you have, the patients can always figure out if you have performed a procedure before or not. Is it non-teaching hospitals (ones without residents,etc.) that are more likely to limit the nursing students learning experiences?