First Year of Nursing is Hard Because...??

Pediatric Critical Care Columnist · Jan 24, 2008

I think nursing schools fail at preparing new nurses for the real world because many of those teaching nursing don't know what happens in the real world. Nursing faculty members are all advanced-degree holders who may have last done hands-on care when they themselves were students in their basic nursing program. Nursing schools have taken a decidedly academic and theoretical approach to nursing but while knowledge and the theory behind the practice are both important, most of us end up providing direct care without being given the tools to do it proficiently from the start. It isn't important that you can write a flawless paper to AP standards whenyour patient is vomiting up blood. What is important is the critical thinking that goes into deciding what to do about it... after we've cleaned it up.

In school we're so busy learning a new language and dozens of new skills that we don't really have time to integrate all that we're learning into our automatic memory, and we aren't given the opportunity to really get the hang of prioritizing and organizing care for more than two or three patients. As you've seen, in the real world the only nurse who has three patients probably works in an ICU or stepdown unit where the patients are complex and their care even more so. Why is that the way schools work? The clinical instructor may have ten students to supervise, each of whom has three patients, meaning the instructor has to have at least a passing knowledge of thirty patients' diagnoses and care plans, and s/he has to also supervise the care provided to each of them at least part of each clinical shift. See the problem?

Short of completely overhauling nursing education, the only way this issue can be addressed is by ensuring that new grads get a clinical practicum at the end of their didactic education that will help them prepare for the realities of health care delivery. Second, new hires must given an orientation that allows them to integrate what they already know with what they're learning about the unit and how care is priorized and organized for patients on that unit while they have supervision and help. That cannot be accomplished in two weeks, I don't care what kind of a unit it is. The bleak truth is that the shortage of nurses working at the bedside makes those very difficult goals to achieve... a factor that becomes a contributor to the loss of bedside staff itself. When you're run off your feet doing your job and they want you to precept someone else (meaning you're responsible for their actions to a certain degree) you want them to be independent as soon as humanly possible so that your world returns to normal and you finally have some help. Human resources wants them independent because it costs them more than double the money while someone is on orientation. Management wants them independent ASAP so that their overtime costs go down. So orientation is as short as they can make it and still be legal. It's a vicious circle. And we're burning the new nurses out before they've even got their candles lit! That's the biggest shame.

mom2michael, MSN, RN, NP · Jan 25, 2008

I can only base my thoughts on this on my own personal experience and my NS.

It was designed to help me pass the NCLEX and nothing more. Sure I learned diseases, some critical thinking skills and a few actual skills like IV's and Foley's but their primary focus was to give me enough knowledge to take and pass the NCLEX in the end.

Sure I had clinicals but I never actually experienced a "real" day in the life of an RN in 2 years during clinicals. Our time in the trenches of M/S was so scaled down it wasn't even funny. Sure I had check offs on skills and meds and drug calculations galore but we had 2 years to complete those tasks.

For 2 years I was never given a full patient load with all the meds, assessments, admits and d/c's that entail an actual day of an RN. I didn't have to experience the grouchy doctor, the angry family and stressed out co-workers because our clinical instructors shielded us from all evil while in clinicals. I never had to deal with having ZERO support on night shift because once again, we did clinicals during the day on a Thursday where support was all around us.

I graduated from an ADN program that wasn't allowed to "force" us into any additional work so there was no senior practicum or internship in our program where I might have gotten some actual "real" experience during NS. Instead I went from student to GN to RN all w/in 30 days of me graduating from NS and that was beyond stressful!!!!

I was blessed though because I worked with some awesome nurses and doctors the last year that helped me during my transition and taught me MANY valuable lessons.

vaileheart · Jan 25, 2008

Wow thank you both for those awesome replys. I will definately remember what you have written and take it with me while I am in school. I hope to keep these things in mind as I am learning and try to do as much as possible while I have help behind me. I just wanted a more in-depth answer than "the first year is HARD" and you guys gave great reasons. Thank you so much!!! I really appreciate it!!

madwife2002, BSN, RN · Jan 25, 2008

The first year of nursing is hard because we have so many expectations and we dont expect dissapointments. Nursing can be the hardest thing you ever do but the most fullfilling. Enjoy every moment and use the bad things in a positive way.

CABG patch kid, BSN, RN · Jan 26, 2008

Just speaking for myself, I had a lot of confidence in nursing school, but now that I will have a license of my own on the line, there is a lot more responsibility. You can't use the excuse "Oh I'm just a student" anymore. People have higher expectations of you. And there is WAY too much info to learn in nursing to learn in all in school, no matter how we change the education system.

RNJayhawk · Jan 27, 2008

I would say that the first year in nursing is so hard because there is SO MUCH TO KNOW. And not just about diseases, surgeries, etc, which believe me, you and I (as a new grad) haven't scratched the surface of... It sounds really stupid, but part of the reason it is so hard for me is because of transfering/admitting patients. I am an ICU nurse and only have two patients, but when I have to transfer one out, I go out of my mind. Getting orders, doing paperwork, calling physicians to clarify the orders that they wrote wrong, getting pharmacy to get up the last meds that they need before they leave ICU, doing last minute tasks (like d/c lines, call family to let them know of transfer, calling report, sending last minute labs, etc) can completely swamp me. And I can't even imagine having to do this several times a shift like a med/surg nurses, God bless 'em. Truly, it is all of the policy/procedures/paperwork that I have to know that is really the killer. I am three months in, and I wish I would have had some experience with this in nursing school. Sure, I charted on my patients, but I never had to do any busy work because the nurse always did it for me, and I didn't even realize it. I wish I did because I would have felt like I had a better hold on what nursing really is. :pumpiron: Every one told me that I had no idea what the "real world" of nursing was like, and it would make me so mad because they never really explained what it was like and how it was different. And now I am the one who can't really explain it. It really is hard. Learn as much as you can in school when you still have an excuse for asking a thousand questions without looking stupid. But, eventually you will figure it out. Have fun! :specs:

marie-francoise · Jan 27, 2008

This might seem naive of me - but do you think ADN programs should be changed to 1 year of pure didactic (i.e., book learning with lab), followed by 1 year of full-scale immersion-learning in hospital, clinic, and LTC settings?

So, it would be 1 year didactic + 1 year pure clinical? As opposed to a not-so-realistic clinical here and there while we're still trying to get the informational stuff into our heads?

I think that mode of learning would be great, and would more open our eyes to the realities of nursing; but I doubt clinical space would be available for that kind of curriculum structuring.

Anyway, just a thought.

Pediatric Critical Care Columnist · Jan 27, 2008

This might seem naive of me - but do you think ADN programs should be changed to 1 year of pure didactic (i.e., book learning with lab), followed by 1 year of full-scale immersion-learning in hospital, clinic, and LTC settings?
So, it would be 1 year didactic + 1 year pure clinical? As opposed to a not-so-realistic clinical here and there while we're still trying to get the informational stuff into our heads?
I think that mode of learning would be great, and would more open our eyes to the realities of nursing; but I doubt clinical space would be available for that kind of curriculum structuring.
Anyway, just a thought.

In Canada there are no ADN programs and the diploma program is either on life support or extinct. Entry to practice is a baccalaureate degree hence my reference to flawless papers. The calibre of new nurses being turned out lately is for the most part much lower than it used to be in the "good old days". There's a sense of entitlement... "I have a university degree. I am NOT wiping bottoms, I am NOT working nights, I am NOT working weekends, I WILL have my vacation in July..." If you read some of the other threads on this forum you'll find that there are a lot of people who had no idea what they were getting into when they became a nurse and are already planning to quit. It's a huge waste of their time and public resources to give someone like that a seat in nursing program and to spend the thousands of dollars on orientation only to have them decide they never should have become a nurse in the first place.

NurseBean · Jan 27, 2008

First off, I agree with everything JANFRN said in the first post. I am a BSN and can personally vouch for the notion of being being able to write a perfect ADA research paper but feeling like I had no idea what I was doing when I got my first job... Most of the nurses I work with are ADNs from a local community college and I feel like they have had such a better clinical education that I did. There are so many times when I think back and curse my 4-yr program seeing that these girls got through it in 2 years and seem to be much better prepared for the real world, not just writing papers! And by the way, there is no differential for having a BSN over an ADN. The only reason to get your BSN is if you want to continue on for some other advanced degree. :twocents:

mom2michael, MSN, RN, NP · Jan 28, 2008

The only reason to get your BSN is if you want to continue on for some other advanced degree.

There are lots of RN-MSN programs out there that bypass the BSN route all together.

CABG patch kid, BSN, RN · Jan 28, 2008

If the only difference between the ADN and the BSN when first starting out is maybe a more difficult time adjusting, I'm still happy with my BSN. In the area where I went to school, some of the nurses at our clinicals made snide comments about how "The City College students spend more time in clinical than the State students" blah blah blah. How unprofessional of them to make us feel bad about the length of our rotations, something that we had no control over. The state requires an ADN student and a BSN student to have the SAME EXACT amount of clinical hours, its just that the ADN student has a year less to complete them, so the BSN time is more spread out.

Also, I am eligible to get my Public Health certification, and if I want to go back and get my MSN I have less time in school ahead of me. Yes, there are some entry level Master's programs, but they usually require you to have a Bachelor's in something before admission. Plus I've known of a few places that don't like to hire MSN nurses for floor positions, hence, the ADN and BSN nurses will actually have more nursing experience.

Anyway, you can't even tell the difference between an ADN and BSN nurse unless you ask. People just like to make a bigger issue out of it than it really is. Am I proud of my degree? Yes. Will the "B" in BSN help me when I'm first starting out? Probably not and that's fine. The most important letters are "RN" and hopefully by next week I'll know if I earned them. That's all that matters in the end!!!