Crash Course?! Thoughts on RN education

scooterRN52 · Oct 2, 2007

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!

I agree with you, what happened to nursing diagnosis? I think they should learn

more about symtoms and how they should be treated instead of all the mamgement classes they teach. Nurses in all programs get less clinical today, I had 3 classes a week in my ADN program 16 years ago and 3 days aweek in an LPN program 18 years ago. In the RN program we always had post discusison

after clinical.:monkeydance:

jjjoy, LPN · Oct 2, 2007

I think they should learn more about symtoms and how they should be treated

It would seem to me to make more sense to start with symptoms and the immediate response to such symptoms, along with some basic pathophys to understand the reason for those responses.

Most crucial are immediately life-threatening problems... what do do when you find a patient who has stopped breathing or is bleeding profusely? Next, what can a nurse determine from and how should a nurse respond to finding a patient who is... diaphoretic? confused? dizzy? short of breath? And here I mean the most basic of responses, what to do even if you have no idea of the cause of the symptom. Here the main focus would be on assessment... information that could be passed on to the MD... as well as non-medical interventions such as helping a patient find a position where they can more easily get their breath, making sure the dizzy patient doesn't try to get up on their own, etc.

And then move into symptom clusters and how they related to the underlying pathophys and known medical treatments and nursing interventions to deal with such problems. And here I mean general things like increased blood pressure, increased body temperature, nausea, vomiting, diarrhea, erythema, edema, etc. Cover things like the purpose of NG to suction, wound debridement, use of antiinflammatory agents and anticoagulants, etc. Complications that one needs to be on the look out for in hospitalized patients such thromboembolism and sepsis could be covered here.

Finally, cover specific diagnoses and their specific treatment. The students would have to really learn common conditions such as diabetes, CHF, etc. But beyond those most common condiitons, training could focus on taking information from a reference source and applying it in practice... as opposed to expecting the students to learn about every condition they might possibly come across. All students wouldn't have to study hydronephrosis, for example, but they would have they demonstrated the ability to create a plan of care based on a reliable resource about the condition and their own background knowledge of nursing care, medical care, pharmcology, pathophys, etc.

It would still be A LOT to cover... but to me it would make a lot more sense. It's just a general concept. Everyone learns differently though and current methodology seems to work just fine for many.

And nursing diagnoses? Toss 'em! Well, I'd just simplify it to nursing priorities. Students can create lists of priority issues (risk for infection, fall prevention, etc) and their rationale without having to create convoluted sentences or finding some obscurely worded equivalent of the problem.

scooterRN52 · Oct 2, 2007

It would seem to me to make more sense to start with symptoms and the immediate response to such symptoms, along with some basic pathophys to understand the reason for those responses.
Most crucial are immediately life-threatening problems... what do do when you find a patient who has stopped breathing or is bleeding profusely? Next, what can a nurse determine from and how should a nurse respond to finding a patient who is... diaphoretic? confused? dizzy? short of breath? And here I mean the most basic of responses, what to do even if you have no idea of the cause of the symptom. Here the main focus would be on assessment... information that could be passed on to the MD... as well as non-medical interventions such as helping a patient find a position where they can more easily get their breath, making sure the dizzy patient doesn't try to get up on their own, etc.
And then move into symptom clusters and how they related to the underlying pathophys and known medical treatments and nursing interventions to deal with such problems. And here I mean general things like increased blood pressure, increased body temperature, nausea, vomiting, diarrhea, erythema, edema, etc. Cover things like the purpose of NG to suction, wound debridement, use of
antiinflammatory agents and anticoagulants, etc. Complications that one needs to be on the look out for in hospitalized patients such thromboembolism and sepsis
could be covered here.
Finally, cover specific diagnoses and their specific treatment. The students would have to really learn common conditions such as diabetes, CHF, etc. But beyond those most common condiitons, training could focus on taking information from a reference source and applying it in practice... as opposed to expecting the students to learn about every condition they might possibly come across. All students wouldn't have to study hydronephrosis, for example, but they would
have they demonstrated the ability to create a plan of care based on a reliable resource about the condition and their own background knowledge of nursing care, medical care, pharmcology, pathophys, etc.
It would still be A LOT to cover... but to me it would make a lot more sense. It's just a general concept. Everyone learns differently though and current methodology seems to work just fine for many.
And nursing diagnoses? Toss 'em! Well, I'd just simplify it to nursing priorities. Students can create lists of priority issues (risk for infection, fall prevention, etc)
and their rationale without having to create convoluted sentences or finding some obscurely worded equivalent of the problem.

I agree with you, but experience really helps, don't you think? I've already walked in and found a patient cyanotic and unable to breath, I got o2 on him right away and called a code blue, we sent him to ICU, he needed a ventilator.A new nurse wouldn't know what to do.Or maybe she would.:monkeydance:

jjjoy, LPN · Oct 2, 2007

... experience really helps, don't you think?

Absolutely! There's no way to substitute for the knowledge and skills that come from experience.

I just know that I was frustrated with the way my program, and I'm assuming several other programs, taught the didactic portion of class. Why did each assignment feel like reading a hundred pages in a reference book? Because my med-surg book WAS written like a reference book. And that's fine, but you don't read to UNDERSTAND from a reference book. You read the reference book to get the facts, then you apply knowledge you already have from other sources to see how you can use that information caring for a patient.

It would seem more important to make sure students have a strong foundation in recognizing and dealing with symptoms, and knowing and understanding pathophys, pharmacology and the like, as opposed to reeling off the symptoms,lab values and treatments of a ton of specific conditions they may not encounter. If there were more time to learn, then fine, study them all. But since time is limited, something has to give.

In practice, the nurse will either already know the diagnosis from the chart or will have to run the symptoms by the MD to get a diagnosis. Whether or not the nurse has a good idea of what the MD will say isn't as important as the nurse recognizing when an MD needs to be called. With experience and practice, the nurse WILL be able to predict what an MD will order. But with just two short years of training, not all of which is hospital-based nursing, and the current situation where students often don't get the amount and kind of first hand clinical experience to that would truly break them in professionally, a basic nursing education can only cover so much ground.

I'm wondering if it still might work if nursing education if there were less breadth of the possible health conditions a nurse may come across, in order to free time to really learn how to be a nurse. If they have that down, it's okay with the nurse gets a patient with a condition he/she isn't very familiar with - that's what reference books are for.

Maybe highlight a couple of diseases from each system and then assign students to apply their nursing knowledge to a couple of other diseases from that system, pointing them to reliable reference sources. Finally, quickly review the longer list of the conditions usually covered on that system. As graduates, students will have at least heard of most conditions and they will be well prepared to use available references and resources to create a plan of care and to understand the short explanation of the disease in the reference book and be able to teach their patient about it.

smk1, LPN · Oct 3, 2007

I agree with you, but experience really helps, don't you think? I've already walked in and found a patient cyanotic and unable to breath, I got o2 on him right away and called a code blue, we sent him to ICU, he needed a ventilator.A new nurse wouldn't know what to do.Or maybe she would.:monkeydance:

As a student approaching graduation, I kind of disagree with this. I think the not breathing, found unconscious "code" type situations are things we would know how to handle because we won't be alone making decisions. It would be scary but you know what to do. Person isn't breathing, do ABC's call a code initiate CPR and the calvary comes to rescue you! The issue that I see as a big issue is that hours prior to the arrest the signs of it coming may have been caught by a more experienced person. There is no replacement for experience when it comes to assessment. This is what makes me nervous. We do 2 clinical days per week 8-9 hours. Which is decent, but it could be more. Getting out there and seeing what a real live patient with ____ disease looks like is so important. The education is vitally important as well but the two must go hand in hand for the concepts to really come together.

fronkey bean · Oct 9, 2007

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.

I had a good working knowledge of pathophysiology when I left school so that when I saw something that deviated from the norm I could recognize it and and call the physician w/ pertinent info. I was coached in this for a 6 wk orientation and then put out there on my own and in 13 years have never had a complaint that I didn't call when I should have or that I called when I didn't need to.

Absolutely! There's no way to substitute for the knowledge and skills that come from experience.
I just know that I was frustrated with the way my program, and I'm assuming several other programs, taught the didactic portion of class. Why did each assignment feel like reading a hundred pages in a reference book? Because my med-surg book WAS written like a reference book. And that's fine, but you don't read to UNDERSTAND from a reference book. You read the reference book to get the facts, then you apply knowledge you already have from other sources to see how you can use that information caring for a patient.
It would seem more important to make sure students have a strong foundation in recognizing and dealing with symptoms, and knowing and understanding pathophys, pharmacology and the like, as opposed to reeling off the symptoms,lab values and treatments of a ton of specific conditions they may not encounter. If there were more time to learn, then fine, study them all. But since time is limited, something has to give.
In practice, the nurse will either already know the diagnosis from the chart or will have to run the symptoms by the MD to get a diagnosis. Whether or not the nurse has a good idea of what the MD will say isn't as important as the nurse recognizing when an MD needs to be called. With experience and practice, the nurse WILL be able to predict what an MD will order. But with just two short years of training, not all of which is hospital-based nursing, and the current situation where students often don't get the amount and kind of first hand clinical experience to that would truly break them in professionally, a basic nursing education can only cover so much ground.
I'm wondering if it still might work if nursing education if there were less breadth of the possible health conditions a nurse may come across, in order to free time to really learn how to be a nurse. If they have that down, it's okay with the nurse gets a patient with a condition he/she isn't very familiar with - that's what reference books are for.
Maybe highlight a couple of diseases from each system and then assign students to apply their nursing knowledge to a couple of other diseases from that system, pointing them to reliable reference sources. Finally, quickly review the longer list of the conditions usually covered on that system. As graduates, students will have at least heard of most conditions and they will be well prepared to use available references and resources to create a plan of care and to understand the short explanation of the disease in the reference book and be able to teach their patient about it.

I run into a similar argument from my daughter when she wants to just answer the lesson questions by skimming through the assignment to find the answer w/o actually reading the assignment. The problem is that you learn isolated facts out of context and you don't develop an overall familiarity w/ the subject matter. Of course you are not going to remember all of it, if you could you would have gotten a 100 on every test (assuming you didn't), but when you were done you hopefully had a working knowledge of the normal physiologic processes of whatever body system you were covering and also the pathophysiology. This should put you ahead of the curve when it comes to knowledge gained by experience too. If you already have the knowledge that some nurses have after a few years of experience then it seems to me you would always be a little ahead. It probably evens out after 10-20 years but shouldn't we start as prepared as possible to meet the needs of the patient and facilitate our physician colleagues to do the same?

fronkey bean · Oct 9, 2007

As a student approaching graduation, I kind of disagree with this. I think the not breathing, found unconscious "code" type situations are things we would know how to handle because we won't be alone making decisions. It would be scary but you know what to do. Person isn't breathing, do ABC's call a code initiate CPR and the calvary comes to rescue you! The issue that I see as a big issue is that hours prior to the arrest the signs of it coming may have been caught by a more experienced person. There is no replacement for experience when it comes to assessment. This is what makes me nervous. We do 2 clinical days per week 8-9 hours. Which is decent, but it could be more. Getting out there and seeing what a real live patient with ____ disease looks like is so important. The education is vitally important as well but the two must go hand in hand for the concepts to really come together.

I agree w/ you in part but I think even a new nurse should be able to recognize subtle signs that something is different w/ her patient and have enough knowledge to investigate further and consult other people. How many times have those of us in ICU reviewed NN and seen a trend developing that, if it had been caught and treated earlier, might have averted the code?

jjjoy, LPN · Oct 9, 2007

I agree w/ you in part but I think even a new nurse should be able to recognize subtle signs that something is different w/ her patient and have enough knowledge to investigate further and consult other people. How many times have those of us in ICU reviewed NN and seen a trend developing that, if it had been caught and treated earlier, might have averted the code?

First you say a new nurse should be able to recognize subtle changes and then you note that it's not uncommon to find that such signs were not recognized by experienced nurses you work with.

Yes, ideally all new grads would be well-prepared... but they aren't. Just like there are practicing nurses who don't seem to make the grade. The question is whether those who show deficits have had their chance and shouldn't be nurses there or if they just need additional education and training. You probably don't treat newbies poorly, but too many experienced nurses give newbies a hard time for not being able to "hit the ground running" and to know things right off the cuff - which, given the way many programs are run these days, isn't a realistic expectation.

jjjoy, LPN · Oct 9, 2007

I run into a similar argument from my daughter when she wants to just answer the lesson questions by skimming through the assignment to find the answer w/o actually reading the assignment. The problem is that you learn isolated facts out of context and you don't develop an overall familiarity w/ the subject matter.

I completely agree! That's why I didn't like the way the nursing texts were structured. They focused on each condition separately. 3-4 pages with a short pathophys section, a list of signs and symptoms, a paragraph or two on diagnostics and treatments and finally a section devoted to nursing care. Was I to seriously memorize all of that for every condition we covered? I didn't just want to memorize, I wanted to understand, to see the relationship between the symptoms, the lab values, the mechanisms by which the treatments worked... but with as much as we had to cover, there was never time to ask questions in lecture. And the text didn't integrate the material that way. Yes, we all need to be able to teach ourselves things, but I don't think many would argue that nursing should be a self-study course.

Just in case you have the impression that I think nursing school should be easier, let me clarify that I don't think that! I earned very good marks in nursing school as well as my other subjects, including the sciences and AP classes in high school. I spent many a weekend throughout school in the library. I'm no slacker when it comes to studying.

I just felt that for all of the hard work that nursing school was, I didn't feel like the learning objectives were clear. What were we to do with those thousands of pages of info we covered in the med-surg booK? With the 3-4 pages of hundreds of disease summaries? Study it for the exams? Well, yes, of course. But remember, it's NCLEX-style exams... so really, skimming worked just fine for test preparation. What were were supposed to come out knowing? How to provide nursing care for those patients, presumably... well, I could write a darn thorough nursing care plan and apply nursing diagnoses!! But that doesn't mean I know what to do without careful referencing and doublechecking... things which practicing nurses don't have much time for.

I'm still clarifying my thoughts on this. That's why I started the thread. That's for participating! :monkeydance:

smk1, LPN · Oct 9, 2007

I agree w/ you in part but I think even a new nurse should be able to recognize subtle signs that something is different w/ her patient and have enough knowledge to investigate further and consult other people. How many times have those of us in ICU reviewed NN and seen a trend developing that, if it had been caught and treated earlier, might have averted the code?

But this just illustrates my point. If this is happening with experienced nurses then how much more so is the risk that a new grad is going to miss something, or be unsure of what they are seeing. What is obvious to someone with a lot of experience is not ncessarily obvious to those with little. Clear objective data is not as hard to miss MAP falling significantly, clear change in mentation, Large BP changes, breathing difficulty etc... it is the little things that don't seem to mean much on their own, but for someone with experience that can easily put it all together, well the devil is in the details. We will hopefully all get there but it is scary to think of the time it is going to take.

scooterRN52 · Oct 10, 2007

Absolutely! There's no way to substitute for the knowledge and skills that come from experience.
I just know that I was frustrated with the way my program, and I'm assuming several other programs, taught the didactic portion of class. Why did each assignment feel like reading a hundred pages in a reference book? Because my med-surg book WAS written like a reference book. And that's fine, but you don't read to UNDERSTAND from a reference book. You read the reference book to get the facts, then you apply knowledge you already have from other sources to see how you can use that information caring for a patient.
It would seem more important to make sure students have a strong foundation in recognizing and dealing with symptoms, and knowing and understanding pathophys, pharmacology and the like, as opposed to reeling off the symptoms,lab values and treatments of a ton of specific conditions they may not encounter. If there were more time to learn, then fine, study them all. But since time is limited, something has to give.
In practice, the nurse will either already know the diagnosis from the chart or will have to run the symptoms by the MD to get a diagnosis. Whether or not the nurse has a good idea of what the MD will say isn't as important as the nurse recognizing when an MD needs to be called. With experience and practice, the nurse WILL be able to predict what an MD will order. But with just two short years of training, not all of which is hospital-based nursing, and the current situation where students often don't get the amount and kind of first hand clinical experience to that would truly break them in professionally, a basic nursing education can only cover so much ground.
I'm wondering if it still might work if nursing education if there were less breadth of the possible health conditions a nurse may come across, in order to free time to really learn how to be a nurse. If they have that down, it's okay with the nurse gets a patient with a condition he/she isn't very familiar with - that's what reference books are for.
Maybe highlight a couple of diseases from each system and then assign students to apply their nursing knowledge to a couple of other diseases from that system, pointing them to reliable reference sources. Finally, quickly review the longer list of the conditions usually covered on that system. As graduates, students will have at least heard of most conditions and they will be well prepared to use available references and resources to create a plan of care and to understand the short explanation of the disease in the reference book and be able to teach their patient about it.

I think a nrsg. student should be able to apply some of their knowledge when they graduate. When they first take care of patients they should know what is nomal. If they see something that deviates from the norm they need to call the Doctor. They should collect all of the data first; symptoms, labs that are abnormal,

etc.

A new nurse is not expected to know everything, but she should be smart enough to seek the assistance of a more experienced nurse.It takes years of experience to learn and be able to recognize a disease process and know what should be done, but it helps to know your A&P and understand pathophysiology.

nanacarol · Oct 10, 2007

When I was in nursing school, I probably felt as you do, however, I now realize the positive impact all that information and repetitive lectures and plan of care writing have served me well. I am able to assess a patient on admission and develop my own differential diagnosis, set a true working plan of care, I was introduced to the concept that my assessment ability was only as valuable as my ability to get the patient involved in the plan. Pharmacology was a critical course for me and I believe for any nurse, because I am able to use the symptom review I learned by repetition many, many times I can, at a glance identify existing and potential medication issues. I read your statement and I came away feeling that your personal expectations were centered around "being prepared" to be a functioning nurse, that doesn't happen and even if school became an arena where the emphasis was on the tasks the perform, those are not what make us nurses, they are merely tasks. We must be prepared to think critically and we must be taught to take the information we gather and analyse it so we have a premise "before" we call the physician. The instructor is trying to get the student to that point via repetitive reading and regurgitating the information with an eye for differences, those subtle, gut utterances. When you get to that point you have arrived on the first platform of the nursing profession. As you traverse the upper levels of academia you will be introduce to broader ideas and concepts, through it all you will be encouraged that the beginning "grunt" work was worth it. nanacarol