Made a fool of myself to board of nursing rep

[Lemon Bars]

So, a representative from the California Board of Registered Nursing visited our school and asked us for feedback on our program. We had been encouraged to be on especially good behavior during the visit, but I couldn't keep my big mouth shut when the rep said that we should all be looking to the future to get our DNP degrees. I told her that I felt our BSN program seemed designed to push us towards grad school, but that I personally had no plans to become a nurse practitioner or to get an advanced nursing degree. I told her that I felt our program put too much emphasis on pathophysiology and clinical decision-making from the point of view of a physician or nurse practitioner and that we hardly spend any time in lecture discussing nursing procedures, nursing care, or the role of the nurse.

The Board of Nursing representative looked at me as if I was crazy, like I had just complained that the sky was blue. She said it was all about pathophysiology and clinical decision-making "to anticipate the doctor's orders." Am I being ridiculous to expect that lectures will cover nursing care? Is actual nursing care so simple that it does not need to be taught in lecture? Or is it just understood that any nursing care will be learned in clinicals and on the job?

I'm 75% of the way through my BSN program and I still can't wrap my head around how material is presented. It is always from the point of view of a physician; taking a history, doing a physical exam, deciding which diagnostics and lab tests to order, reviewing lab results, making a medical diagnosis, deciding which medications to administer, deciding whether the patient will need surgery and so on.

There are never any phrases in our case studies or lectures such as, "Given these findings, what diagnostics would you expect the DOCTOR to order next?" Or, "Dr. Jones has prescribed amlodipine. Do you think amlodipine is the right medication for this patient?" It may have been stated by an instructor early in the program, but I cannot recall any instructor saying, "Now I know that you are nurses and that in real life you cannot prescribe medications except under certain protocols, but in this class we are going to present all material as if you were physicians so that you can understand how a physician thinks and therefore you will be able to realize if a physician has made a mistake in planning treatment for a patient."

Instead, material is simply presented as if we ARE the doctors. It's very strange. It's like preparing to work at a hospital where there are no physicians, only nurses making all decisions. I get the idea of learning some pathophysiology and clinical decision-making to understand what's going on with the patient and how the medications work, but it just seems weird that I am expected to make medical diagnoses and prescribe medications without going through the more extensive pathophysiology and pharmacology training that physicians are given. I feel like I'm already being pushed to become a nurse practitioner before I've even finished RN school.

Is this normal for a BSN program? How can I adjust my thinking so that I don't feel frustrated? Thank you very much for any advice.:)

[llg, PhD, RN]

I think that you might be right about linking the style of teaching with the fact that most of your instructors are Nurse Practitioners. For some people, "nurse" has become almost synonymous with "nurse practitioner." I think that you are making a valid point that should be taken seriously.

The fact that you have done a few caths, started an IV, etc. is good. Nursing technical skills are important, too, and too many programs have failed to teach them well enough. However, there is no need to do 100 of them -- a few should be sufficient to introduce you to the skills and your employer should be able to give you additional practice with them after teaching you their particular protocols and procedure statndards. But you should be getting class material on the science behind these skills so that you understand the skills.

So ... I think you raise a legitimate concern. In many schools, the pendulum has swung to far in the NP direction. Entry level programs should not be teaching from an NP perspective and/or teaching the NP role (unless they are entry-level NP programs). They should be teaching staff nurses skills from a staff nurse role perspective.

[Flatline, BSN, RN]

I think that you might be right about linking the style of teaching with the fact that most of your instructors are Nurse Practitioners. For some people, "nurse" has become almost synonymous with "nurse practitioner." I think that you are making a valid point that should be taken seriously.

The fact that you have done a few caths, started an IV, etc. is good. Nursing technical skills are important, too, and too many programs have failed to teach them well enough. However, there is no need to do 100 of them -- a few should be sufficient to introduce you to the skills and your employer should be able to give you additional practice with them after teaching you their particular protocols and procedure statndards. But you should be getting class material on the science behind these skills so that you understand the skills.

So ... I think you raise a legitimate concern. In many schools, the pendulum has swung to far in the NP direction. Entry level programs should not be teaching from an NP perspective and/or teaching the NP role (unless they are entry-level NP programs). They should be teaching staff nurses skills from a staff nurse role perspective.

Nursing has become too complex. Look at healthcare 20 years ago and what nurses were doing compared to today. I know registered nurses, not advanced practice, that are placing ports, pulling bone biopsies, etc.

I do not think nursing schools have swung too far over, I think healthcare has just become far more complex and schools are trying to cram more into a fixed size program.

[Castiela]

A lot of those skills you listed I had never done until I entered critical care 2 years after graduating. And even then, I didn't learn in the classroom, but from reading the policy and doing them with my educator.

[SummitRN, BSN, RN]

It is easier to learn a skill/procedure. It is harder to know why we do it, how it works and relates to the big picture, and when to do it (and often more importantly, when not to). You are valued for your knowledge first. That is the difference between a clinician and a technician.

A bedside nurse is not just a technician. You will be the closest observer and primary advocate of the patient. You can't ADOPIE or critically evaluate provider orders without pathophys, diagnostic thinking, and an understanding of EBP.

On the "DNP for everyone" stuff, yea, schools push that hard because it is job security. There is nothing wrong with not wanting to get a DNP!

Our instructor will talk about how we should have known about the low platelet lab value and that we should have prescribed a different medication or tried a different treatment first. Missing from the discussion is how a real nurse would handle a real situation such as this. Missing is guidance on the nursing role such as, "Okay let's say Dr. Smith ordered the anticoagulant, but now you've checked the labs and the platelet count is too low, what will you say to Dr. Smith and what alternative medication or treatment could you propose to Dr. Smith that would be more beneficial to your patient."

I get what you are saying here, but from the fact that you are asking it, you are already on track just fine. The finesse comes from practice and experience with individual providers. Strategies for questioning or suggesting treatment is absolutely something you should be learning in clinical and simulation.

[anewsns]

I hear what you're saying. I think schools should be more thorough teaching skills as well, I feel like it's too much of a focus on them right out of school and it's a hinderance. Perhaps just more of a balance. And wording things like you're going to be a provider sounds strange. Your example about the platelets, how you worded it in the second response sounds more accurate to what it should be like. I can see where the anxiety is coming from. My 2 year program did a pretty good job at covering most of this stuff . I would imagine a 4 year program should be able to cover all of it , with an additional focus on leadership and roles requiring a broad perspective.

[JKL33]

Yes, I think it would be important for you to understand how a bedside RN must process these things (while at the same time I do think that doing a case study from the ED view is great for overall assessment and critical thinking skills, etc).

I agree with llg/post #10.

I started to write this earlier and got called away:

Well this may not be fashionable but I disagree that we should say things like "anyone can be taught _______." Hands-on skills are part of bedside nursing and to not give them their due significance is a mistake IMVHO. There are plenty of people who don't perform these skills well, don't know the appropriate circumstances in which to perform them, and don't know the mechanical and scientific principles behind them, further contributing to the idea of not being able to do them well. I suppose anyone can be a surgeon too? If you can fog a mirror you can be taught to cut here, here, and here, clamp this and that, and it's all good? Is it okay if you can't effectively bag a patient with BVM? Or how about simply not knowing how to properly obtain NIBP? People seem to think it's a matter of pushing a button, and yet it can be messed up if you can't choose the correct cuff size or placement - then patients can be prescribed incorrect treatments or treatments they don't need.

All of it is important.

ETA: To that I will add that you should have some exposure to the most common hands-on skills and it sounds like you are getting that for the most part. I don't think students messing with things like vents is very common, nor is it necessary. But I do think that RNs should be able to do well the skills that they will most commonly be delegating to UAPs and the skills that bedside RNs perform frequently. As I've said in other discussions, I don't think it's appropriate to come out of any RN program, whether ADN/ASN or BSN and not have a very decent handle on the skill portion.

[OCNRN63, RN]

I think that you might be right about linking the style of teaching with the fact that most of your instructors are Nurse Practitioners. For some people, "nurse" has become almost synonymous with "nurse practitioner." I think that you are making a valid point that should be taken seriously.

The fact that you have done a few caths, started an IV, etc. is good. Nursing technical skills are important, too, and too many programs have failed to teach them well enough. However, there is no need to do 100 of them -- a few should be sufficient to introduce you to the skills and your employer should be able to give you additional practice with them after teaching you their particular protocols and procedure statndards. But you should be getting class material on the science behind these skills so that you understand the skills.

So ... I think you raise a legitimate concern. In many schools, the pendulum has swung to far in the NP direction. Entry level programs should not be teaching from an NP perspective and/or teaching the NP role (unless they are entry-level NP programs). They should be teaching staff nurses skills from a staff nurse role perspective.

Thank goodness. I was beginning to think I was the only one who thought the same way.

OP, don't get too hung up on nothing experience with programming an IV pump/using other equipment. Many of those sorts of things are facility specific, so it's something you'll learn when you have your orientation as a new employee.

Some of what you are saying does make sense. While a nurse needs to know above and beyond that of a doctor's handmaiden, it seems like education is getting away from some of the basics. For e.g, I was recently in the hospital and I had a student nurse one day. She said she needed to do patient teaching with me and I said "OK." Her patient teaching wound up being no more than leaving a printout of something at my bedside. She never went over it with me; just left it.

I wonder if nursing programs feel that it's up to the hospitals/employers to teach new grads the staff nurse role.

[KatieMI, BSN, MSN, RN]

Once you hit the real nursing world and stay there for a few months, it all will make sense for you. It doesn't matter where you'll spend these few months - from high-tech ICU to ALF, it will happen. I promice.

You'll sure meet more than one nurse who would be "task-oriented" and tell you that in good 'ol day they spent three and four years mastering skills and had lecture courses solely dedicated to them. I saw curriculum of one such course from 1910th in one of European museums of nursing - it was year long and had full two parts, two hours each, about giving bed bath, for one example.

Unfortunately, it is not so anymore. In current medical world, providers are already spread too thin, and it doesn't seem that things are going to get better any time soon. You are not going to be an order-taker and task-doer as a nurse; you're going to be doctor's ears, eyes, hands, and - to certain extent - brains. The responsibility for improper meds/incorrect doses, missed complications, omitted pieces of history would be shared between you and the provider. In addition, no one would conveniently provide you with all necessary information you must know to care for each patient - so, if, by a chance, you get a guy with Peutz- Jeghers syndrome admitted for a broken ankle, it will be on you to figure out how to care for him, what to expect and what to watch for - and you'll be happpy if given 15 undisturbed minutes to frantically search the Web.

You just won't do it without pretty good grasp of pathology and pharm. Do not worry - you're not going to dive into biochem, molecular pathology, differentials and many other really fascinating things. You'll pretty much have to deeply scratch the surface - but you must do it in order to be a nurse today.

And, yeah, many students nowadays go to BSN programs with no plans to ever work bedside. It is a different question why it happens and if it does any good to anybody but grad schools, but this is just a fact of life. It is every one's right to do whatever with any degree they earned.

[Orion81RN]

I read your post in the students forum and chose not to respond because I was speechless. Well, more like the only words I had to say sounded mean. I thought, "is this chick for real???!!!" You put in the title of your post that you came off foolish to the BON visitor. You absolutely did. At this point you appear extremely naive as to what the role of a nurse is. Even if you don't want an advanced degree, (neither do I at this point) the content in lecture sounds 100% appropriate. You will be forever greatful to the knowledge you are gaining once you are working as a nurse.

It is absolutely our role to question the orders MDs and NPs give us. They make mistakes too. We're the last stop to that patient getting the right med or tx. Many a nurse has been depositioned and grilled as to why they gave a med that turned out to be inappropriate. "The MD ordered it; I gave it," will NOT save you.

Many times I have been asked by an MD or NP "what antibiotic do you think we should give?" They have genuinely wanted my opinion. Also, when I report a change in condition, they give me the slew of orders and either ask if there is anything else I can think of to do, or they DO forget something and I offer it up. For example, I'll say, "how about neb treatments as well?" And where did I get that knowledge? Learning in depth pathophysiology and pharmacology.

The time to learn hands on nursing procedure is in lab and clinical. If you feel you aren't getting enough of that, spend more time during open lab hours. During clinical, ask your instructor, "next foley insertion needed, wound care, ng tube insertion, IV start,... can I do it? "

I DO disagree with the overwhelming push to be ANPs. Encourage continuing education, absolutely!!!! PUSHING for ANPs? Nope.

I recently started reading my old posts as a newbie and cringe, and sometimes laugh, at how naive I was.

Hopefully you will do the same in this case and thank your lucky stars you are getting a stellar education.

P.s. If you truly have no desire to perform the role of a nurse in its entirety...critical thinking, lab interpretation, MD and NP collaboration, and wish to do mainly hands on skills, I suggest switching to maybe a medical assistant program where you can eventually work for a doctor and do a slew of cool hands on procedures.

[Jules A, MSN]

So ... I think you raise a legitimate concern. In many schools, the pendulum has swung to far in the NP direction. Entry level programs should not be teaching from an NP perspective and/or teaching the NP role (unless they are entry-level NP programs). They should be teaching staff nurses skills from a staff nurse role perspective.

This was what stuck out to me. Its bad enough that the schools, who are making serious money on this initiative, are shoving this down everyone's throats but the board of nursing now also?

[Orion81RN]

Thank you so much for these responses. I'm going to address some things to hopefully further the discussion, but please know that I'm not trying to be stubborn or snarky.

"I'm not trying to question you if they are indeed using verbiage such as "what would you diagnose" - which, by the way is an entirely different implication than asking what condition you believe a patient might be diagnosed with..."

My instructors are indeed using verbiage as if we are directly responsible for making the medical diagnosis and prescribing the medication. Many of my instructors are nurse practitioners, and it makes me wonder if they are unable to step out of the provider role.

"Nursing tasks are not the definition of nursing. Anyone can learn to cath, place an IV, rectal tube, do trach care and so on...And before you go on the floor as a brand new nurse, thinking that you've been taught everything there is to know about nursing, you don't. You know enough to barely practice safe nursing. You know nothing, but you will think you do."

Well, it's been two years and I've only done two urinary catheters and three successful IV sticks. I've given a grand total of one IV push medication. I hung my first IV medication and programmed a real IV pump for the first time just a couple of weeks ago. I've only helped change a bandage three or four times. I've never done a rectal tube, never done trach care, never set up a chest tube drainage system, never touched a ventilator, never drawn a blood sample, never collected a sputum specimen, and never done a nasal swab. There are probably a dozens of nursing tasks that I am unaware of or unfamiliar with. I certainly don't feel like I know everything. As it stands right now, I feel incompetent when it comes to many actual nursing tasks in the hospital.

"If your concern is that your program is light on the specifics of nursing, that's a different problem. Are there nursing-specific things that you feel you aren't being taught?"

As I mentioned above, there are many nursing tasks that I have not practiced. But here's a different example of what I mean: We do case studies and we have a patient with such and such history and who presents with certain symptoms. These patients have always just arrived at the ED in need of an accurate medical diagnosis and treatment. It's not the case that these patients already have a medical diagnosis and are now being transferred into our care on the floor. They are fresh patients who need a complete medical workup by a medical provider before they can be admitted into the hospital. We take the history and do the medical workup from the perspective of the physician.

In the second half of class, we have a discussion about how we treated the patient. Let's say we make a mistake; we give an anticoagulant to a patient who has a low platelet count and is already at grave risk of bleeding. Our instructor will talk about how we should have known about the low platelet lab value and that we should have prescribed a different medication or tried a different treatment first. Missing from the discussion is how a real nurse would handle a real situation such as this. Missing is guidance on the nursing role such as, "Okay let's say Dr. Smith ordered the anticoagulant, but now you've checked the labs and the platelet count is too low, what will you say to Dr. Smith and what alternative medication or treatment could you propose to Dr. Smith that would be more beneficial to your patient." Rarely or never hearing about the role of the nurse in lectures and discussions is causing me confusion and anxiety. (However, we do have a simulation class where this type of interaction with a physician is simulated and practiced. So I'm finally starting to get the idea of how this all works.)

Is my point of view starting to make sense? I expect clear explanations for why I'm learning what I'm learning and how I will put the knowledge to use in my work. I expect to know how to function in my role as a nurse when I graduate from my nursing program.

I definitely get the frustration of not getting, in your opinion, enough hands on technical skills. I was quite frustrated with this myself in *big shock to a pp* my ADN program. Even in clinicals it was all about the patient's history, meds and patho. I appreciate that emphasis now, though. Much of the skulls check list we DID learn in lab, I have never even had to do in my career. And what I have had to do, I simply learned on the job. Its hard going into a job after graduation and not knowing how to do hands on skills and having to find a nurse just as busy as you to teach you. But, in the grand scheme of things, that is how it should be done. Even doctors don't know procedures until they are out of med school and in their internships and residencies. Hands on tasks is the easy stuff. Patho is not, and therefore should be the main focus in school. Especially lecture.

Still if you want more hands on, do as I stated before and be as proactive as you can be with grabbing ANY task in clinical you can get your hands on. You still won't get as much as you expected, but don't fret about it. You learn it on the job. You could hang 20 IVs in clinical only to start your job and see they have IV pumps you've never seen before. Same with feeding pumps. Same with IV start kits (or lack of start kits where you have to hunt down each item you need individually.)

My school too worded questions "what is the correct diagnosis?" But who cares how its worded. No, we don't technically diagnose, but you should still know the answers on your exam. So stop getting hung up on the wording.

[llg, PhD, RN]

I think some people may have misinterpreted my earlier post (#10). I don't think it entry-level nursing programs (ADN or BSN) should emphasize technical skills -- and NOT teach physiology, medications, etc. Rather, I believe all of that content should be taught in terms of the staff nurse role and not the NP role. Physiology, phathophysiology, pharmacology, etc. are all critical to the staff nurse's role and should be taught -- and taught well. It's just that faculty should remember that they are educating staff nurses in that program and not teach from the NP perspective. The perspective (and the wording) are important.

Health care is complex and different members of the team have different roles. We all need solid grounding in our roles in order to maximally effective as members of the team. Blurring the roles for beginners does not help. By trying to teach beginner-level students other people's roles, their own role gets shortchanged. Nursing students should get their feet firmly on the ground as entry-level nurses before moving on to learning about other people's roles on the team. That would strengthen their personal worth as nurses and also strengthen the nursing profession. Confusing the roles and perspectives weakens the nursing element.