Employer's Negative Response to Teaching Hospital Experience

[slr0610]

Hi all,

Excuse me why I vent/reach out for advice on a situation.

This may get lengthy, but again just trying to vent and give all details for some good advice. :)

Soooo.....I have worked in a major, well-known teaching hospital for my first 3 years of being a nurse. I have worked in an ICU setting for all three years and have my CCRN. Recently, during my quarterlife crisis :)......I decided that I wanted to move back to my hometown to be closer to my family.

I had my first of a couple of interviews lately at a mid-sized hospital in a large suburban area. I was contacted by HR and told my resume was impressive..woohoo...so they brought me in for an interview. I met HR at their office and she walked me over to the unit to interview with the managers....

We get to the unit and there are no managers there. After about 20 minutes, the HR person was frustrated and apologizing, saying that this interview was on both of the managers' schedules. At this point, I'm less nervous, more relaxed, very "I'm gonna go with the flow". About 10 minutes later, the managers show up saying a meeting ran late....I totally understood. Cool.

One of the managers said this was only her second week on the job, however, she did most of the questioning. I felt like some questions were just kind of "off"...which is why I don't remember a lot of the questions she asked.

Soooo....here it comes. They go over my resume. I told them one example of when I dealt with a difficult situation at work...which envolved communication between different residents and NPs. IMMEDIATELY, the rest of the 20 minute interview was focused on what support do you have at your teaching hospital? Do you understand that you won't have that personnel available here? How will you make the adjustment?

(Let me just add since they focused on this topic for the last 20 minutes...they really didn't go into any depth with my experience with patients....performance based questions, etc....which is where i hoped to shine)

Sure, I said.....I know it will be an adjustment. I am a quick learner and am a flexible, laid-back person. I will be able to learn and adjust to the different environment. I am ready for a change and a new environment. I think that seeing a number of different things at a teaching hospital can hopefully prepare me to work in new settings.

Still two of the managers continued...but, tell us a specific example of when you helped a patient/did an intervention for a patient/called an attending directly for a patient. Tell us when YOU did something?

So, sure....I gave them an example of where I had to call an attending directly since a resident wasn't responding to an urgent need. One manager was please with the answer. The newer manager continued....but, did YOU call the attending, or did your charge nurse call the attending?? Or did you have a NP that called?

Huh, what????? Am I incompetent somehow? Does working with a greater number of people mean that I have less communication skills?...I simply replied that no, I called directly for my patient. And I went on to say that I worked night-shift for over a year where....mid-level providers weren't always available. But they seemed not to care about that.

How are you going to care for patients with no-mid level providers readily available? How are you going to adjust??

(Didn't I just answer that question?) So I repeated basically my previous answer again. ONLY to be questioned once more on the same topic.

Again, this went on for 20 minutes.

Look, I COMPLETELY understand that they want me to really know that working in their unit would be a different environment and I need to realize "what I would be getting into"............But, I this point I kind of felt like the attitude was "you work at a teaching hospital where you have lots of residents and NPs to do everything, so do you really know how to take care of patients without them?" You. are. a. spoiled. nurse.

I get it. And I know that at teaching hospitals, sometimes, nurses can have less autonomy just based on all the providers involved in care. I know it would be an adjustment leaving. HOWEVER, does working at a teaching hospital somehow make me less competent/able to care for patients?? The acuity of our patients and patient needs are VERY high and critical. We see, do, and precept A LOT. And I guess I just don't understand, because I thought employers would like experience in a teaching hospital....experience with lots of students, bedside procedures, high acuity patients, seeing lots of different things, experience rounds, blah. But, I felt that I was being attacked here for working at a teaching hospital multiple times in the interview. That somehow I was less competent and had less communication skills due to all the resources I have at my current job. I also have my CCRN and have taken many continuing education courses. Guess that didn't matter.

Again, sorry for the length. And this experience is still fresh, so sorry for the venting..but I just wanted to ask...am I justified in feeling this way?.....just very disappointed they were knocking my experience at the type of hospital I work at instead of inquiring with performance-based questions. Or maybe having to wait and the "new" manager threw me into a mood? Or maybe the new manager was off?.....or Has someone experience this before and can vent on a similar situation? Advice for the future?....OR im just crazy?

Ok breathe....

Thanks...y'all are the best. :)

[trueblue2000]

Fully expecting and prepared to be flamed for this post, I will say the following:

You walked in the interview thinking you were the big shot - CCRN, major teaching hospital experience - and they sort of put you in your place. The big casualty of this encounter seems to have been your ego, bruised by the fact that the interviewers did not bow down to you but instead did what they were supposed to do, which is to grill candidates with pertinent questions. Maybe this was a needed humbling experience for you. Such is my reading of what transpired.

[dishes, BSN, RN]

I disagree trueblue, managers don't have time to waste to conduct interviews to "put nurses in their place".

slr, your answers may have showed that you recognized there is a difference in the two ICU environments and that there are different role expectations, but seemed vague like a beginner nurses answers, if they did not sound like your ICU experience has lead you to be an analytical thinker who easily moves from follower role to leadership role when necessary, then I can see why the managers kept trying to draw that information out of you. That being said the interview doesn't sound like a total wash to me.

[Annaiya, NP]

Fully expecting and prepared to be flamed for this post, I will say the following:

You walked in the interview thinking you were the big shot - CCRN, major teaching hospital experience - and they sort of put you in your place. The big casualty of this encounter seems to have been your ego, bruised by the fact that the interviewers did not bow down to you but instead did what they were supposed to do, which is to grill candidates with pertinent questions. Maybe this was a needed humbling experience for you. Such is my reading of what transpired.

Wow, that was completely not my reading of her post. I too have 3 years ICU experience and my CCRN. I don't know if you've taken the exam before, but it is HARD! It takes dedication and a brain to pass it. After 3 years of experience, if you are a good nurse, keep up to date on current practices, a good team player, etc., you should be able to expect to walk into any ICU and get hired. It isn't arrogance, it's confidence in your skills and knowing you are an asset to the unit. The managers sound like they either don't know what they are doing, or they are allowing a bad experience in the past to completely cloud their judgement of future candidates. It isn't like it's hard to pick up skills like IVs and calling an attending directly. The attitude and ability of the nurse should be the focus. A nurse with 3 years of experience and CCRN, should have the ability to learn those things quickly. Certainly better than training a new grad!

[caroladybelle, BSN, RN]

Having started in community hospitals, and having transitioned to a very wellknown teaching facility, as well as having been a traveler in both, there can be big differences.

I have worked with new travelers that came from teaching facilities that had never done some of the common tasks that floor nurses do, and vice versa.

Not always true, but some differences that are often noted.

- more ancillary departments: Rts that do the vent changes, nebs and draw peripheral ABGs. Social work that sets up appointments, speech therapy, etc.

- med students/interns starting IVs or being expected to draw from central lines on the nonICU floors. I freaked out some interns by drawing my own central line labs on a medsurg floor - it was evidently "their Job".

- NG tubes, dobhoffs and coudet caths often being done by interns.

- most orders at night go through intern/resident/fellow then to attending. But I have never gotten my charge to call an attending. I have seen community MDs require that all night calls go through the charge or a supervisor. And my attendings actually ask us to call if anything is off with the orders given by house officers (less senior MDs). I have found that attendings are much more even tempered and less rude when we call at night. I would rather deal with them than community docs.

- teaching attendings have residents to put in orders, fetch and call. Often community MDs insist on nursing fetch charts, write verbal orders, make calls that they should be making. Also residents to do med reconciliations, fill out DC paperwork in full.

- residents are required to write thorough notes and legibly. Not as common in community hospitals where administration kisses the feet of the MDs and expect nurses to be psychic and translate chicken scratch writing, or review poorly written notes for answers.

- and from what I have observed, nurses are floated less and to more appropriate depts in a teaching facility. The MDs are expected to follow some rules. No trying to sneak in pushing adenosine on a med surg floor, conscious sedation on nonmonitored patients, endoscopy on a medsurg floor, or nurses being asked to tPa chest tube. There is a lot more freedom to say that it is out of my scope, or is not permitted by regs and hold your ground against being asked to do something. Ratios tend to better also in the teaching facilities hat I have been to.

After working my butt off and accruing excellent references from small hospitals as well as several of the preeminent teaching facilities in the northeast, including 4 routinely included in the top 10 in the nation, I went looking for a job in my native Florida. I was getting immediate job offers from the NIH and several teaching facilities, and almost no interest all in the local small (less than 100 bed) facilities, The interviews were very similar responses but virtually every small facility gave me at least a little attitude. I do not brag, I do not say "But they didn't do it that way at Xhospital". It didn't matter.

I can get a job in the best of the best but don't even rate notice in a 60 bed community hospital. Irony.

[applewhitern, BSN, RN]

I worked in a teaching hospital for years. The only time I ever saw an intern or resident placing an IV was a central line or something. The RN's started IV's, placed all N/G tubes, drew ABG's. We didn't have the luxury of having residents around our unit at all times; they rounded early in the morning, then we called them if needed. I learned more, and got far more experience doing procedures at the teaching facility than I ever have anywhere else. We didn't use fancy IV pumps that figured our drip rates for us, either; we did all calculations ourselves with a calculator. Not only that, we had to CHART how we figured the drip rate! This was to help catch errors in calculations of the pressure drips, fentanyl drips, etc. I can't believe anyone would think you don't have autonomy in a teaching hospital! The residents asked the nurses what to do! They always said if you worked there, you could work anywhere.

[dirtyhippiegirl, BSN, RN]

I worked in a teaching hospital for years. The only time I ever saw an intern or resident placing an IV was a central line or something. The RN's started IV's, placed all N/G tubes, drew ABG's. We didn't have the luxury of having residents around our unit at all times; they rounded early in the morning, then we called them if needed. I learned more, and got far more experience doing procedures at the teaching facility than I ever have anywhere else. We didn't use fancy IV pumps that figured our drip rates for us, either; we did all calculations ourselves with a calculator. Not only that, we had to CHART how we figured the drip rate! This was to help catch errors in calculations of the pressure drips, fentanyl drips, etc. I can't believe anyone would think you don't have autonomy in a teaching hospital! The residents asked the nurses what to do! They always said if you worked there, you could work anywhere.

I feel like your experience is closer to mine. However, we do have those fancy pumps. :/ I work at a large academic hospital. The primary RN places all IVs, and deals with/troubleshoots all central lines. Our IV therapy team (RNs) places PICCs and does hard stick starts. We certainly do not have a turn team. RNs place all NGTs, although only ICU RNs are allowed to place corpaks. We pull central lines all the time.

I did many clinicals at community hospitals during school and I get that we do have things that those hospitals don't have. Like 24/7 IV therapy teams; rapid response teams for med/tele; doctor-lead code teams; even just having in-house residents for ICU. I actually did my ICU clinicals in a community hospital and, in retrospect, am amazed at the number of protocols and matrices and standing orders that the nurses had to deal with things before having to call a doc. Like, I *wish* we had those in place for my large academic hospital ICU.

I've had to walk interns and residents through things before. And will have to again coming up in July. :/ And sometimes our residents get so sleep-deprived that they get wacky. ("Doctor, do you really want 25 mg dilaudid IVP?")

However, having rounded with attendings and nurses in a community hospital ICU setting -- whoever likened those nurses to residents is totally right. God help you if you couldn't rattle off all of your patient's lab values from memory. The attendings would even "pimp" the nurses r/t pathophys, etc. But you could also see an elevated level of respect between doctor and nurse which was nice.

Anyway, this is too long and rambling and I worked last night, so there's that. /sigh

[SummitRN, BSN, RN]

I echo the above two posters... in a teaching hospital ICU my experience is that RNs start and d/c IVs, NGTs, dobhoffs, foleys, draw their own ABGs, central line draws, wedges, and d/c central lines, art lines, and Swan/Ganz. We have no midlevels and are expected to catch the intern and resident screwups, advocate hard for intesivist practices with new and hesitant R1s/R2s, participate in rounds (better know all the lab values), are expected to be the semi-intensivists of sorts, even running codes or at least acting as the co-pilot for the wide-eyed PGY1.

[Do-over, ASN, RN]

Just to add my two cents...

I have seen that sometimes it is a huge adjustment for nurses coming from "University of Bigtown Medical Center" to "Rural Community Hospital". I have only worked in the sticks, so I don't know any different. I often wonder what it would be like to work in one of the big Level 1s... Maybe someday I will give it a shot.

Just to play devil's advocate, and as someone who used to conduct interviews (although not for nurses), it is a huge undertaking, and you want to do everything you can, as the manager, to make sure you hire someone that will fit in and will be around for awhile.

All that being said, an interview is also the time for you to decide if this is a place you want to work, and if these are people you want to work with. Considering you had such a negative reaction to the interviewers - you might have your answer.