The culture of nursing - Professional behaviour & conduct

  1. I'm currently a second year student and getting ready to go on my first clinical placement as a second year in two weeks time. I'm really, really looking forward to placement, especially now that we have a larger repertoire of skills to perform. I'll be going to a medical oncology ward and I'm looking forward to learning about different aspects of cancer and participating in cancer care. However - I have had problems with my clinicals in the past. Prior to my last placement (August, 2009) I posted here seeking opinions and advice from seasoned nurses as to how to improve myself and I received some absolutely astounding feedback. I am sure that the feedback I received and the reflection that it prompted within myself played a significant role in my passing that placement, though it was still a very close call. You can read that post HERE if you're interested.

    Anyway, the reason I am posting today is that while I'm incredibly excited about going on this next placement, I'm also acutely aware that even though my practical and procedural skills are up to par I still have a lot of deficits regarding my ability to practice professionally and appropriately within the scope of a student nurse. I was hoping for some advice and prompting from those more experienced that I am to help my prepare myself to do well on this placement and improve on the areas that I am still lagging behind in, even after three clinical placements.

    Slowly, and after much exposure, I have begun to understand the "culture" of nursing and the place of the student nurse within that culture. Right or wrong, I have developed the impression that nursing can be, all to often, a very cut throat profession with a good dose of passive-aggressiveness and that students are almost always at the very bottom of the food chain. (I'm not suggesting that all nurses are like this. I am insinuating that this has been my experience so far.) While this makes me very sad, I have come to accept that the culture of the nursing workplace may be the ultimate downside to the career of my dreams. However, I'm willing to work through that, which, I guess, is why I'm here and asking for your help.

    I am, by nature, an outspoken person. Further, I'm incredibly passionate about nursing and really want to be as involved as I can in the activities of the ward, though often this means simply observing. Unfortunately, as a bottom feeder in the nursing world, my outspoken, enthusiastic and sometimes loud personality does not sit well with the nurses who have had the unfortunate luck of landing a student on their shift. Being proactive and enthusiastic is often interpreted as just plain getting in the way and I find it difficult to balance meeting my learning needs with not getting in the way and stepping on anybody's toes. However on the other hand, keeping quiet and out of the way is detrimental to my learning and just plain looks bad for a student! Confidence is often interpreted as overconfidence (which I've learnt is a really, really bad image to present and sends nurses running the other way) and I'm not sure how to project a balance of confidence in the skills I do have with uncertainty about skills I'm still unsure of and appropriately ask for assistance without getting in anyone's way.

    I often feel like the simplest way to just pass each clinical to keep quiet, shut up, don't ask questions and just watch unless someone asks you to do otherwise. Obviously it's not ideally appropriate but so often I come up short about the best way to meet my learning needs, not get in the way and just plain pass.

    I know this hasn't been a very clear post. I am so very unsure of what the exact nature of my problem is, which makes it difficult to ask for help. I really hope that there is something - anything - in this that AllNurses members can offer me feedback on. I'd really appreciate your thoughts and opinions prior to my upcoming clinical. More than just passing, I was to be a good nurse and make a good impression. & I don't think I have the knowledge or the skills to do that within the culture of nursing. I'm hoping that your feedback will help me find my feet a little bit more and help me take the next steps toward preparing for my clinical.
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    About rachelgeorgina

    Joined: Apr '09; Posts: 412; Likes: 186
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  3. by   BluegrassRN
    So your problem is you're smart, loud, sassy, mouthy, and think you know it all? Eh, I feel you're pain.

    Basically, from what I read in your post, you worry about coming across with those qualities, and so you back off, don't ask questions; and then you feel that you aren't getting as much as you should out of your clinical experience.

    Because I, too, am a smart, sassy, loud, mouthy, insufferable know-it-all, here's my advice to you.

    Accept that you are not going to have all your questions answered to your satisfaction. This is so difficult for me. A question pops into my head that I can't answer myself, I can't find the answer, dammit, I want it answered. Your precepting nurse and/or your instructor might not know the answer, might not be able to explain the answer thoroughly, or might not understand your question. There are some questions that just do not need to be answered in order for you to be a good nurse.

    Think about your word choice and your tone of voice when asking a question. Do not use accusatory tones or words, placing your preceptor or instructor on the offensive.

    Accept that there is more than one correct way to do nursing tasks. When a nurse does things differently than you learned in school, take care in questioning it. If it is something major, you can go ahead and ask, in a nonthreatening way. If it is something that *really* doesn't make much difference, if it bothers you, you can discuss it with your clinical instructor later. Another good resource is the protocols and procedures manual for the unit (probably online). You can look up a procedure and see how your facility wishes this to be performed; usually the rationales and references are included in each procedure or protocol description.

    Keeping your head down is not defeat or a time waster. Observation *IS* important. So is working things about on your own, instead of asking about them. Respect for the patient and nursing staff is also an important aspect of your education, and although you wish the world to revolve around you, it actually doesn't (I still struggle with this concept...).

    I found that if I only spoke up once every three times that I had a question, I came across as less aggressive, less prickly and less annoying than if I asked every question that popped into my head. Basically, FILTER, FILTER, FILTER was my mantra, and it served me well.

    Good luck. You'll be a fine nurse. Even a less than perfect clinical experience teaches you a lot. Don't forget that.
  4. by   rachelgeorgina
    Quote from BluegrassRN
    So your problem is you're smart, loud, sassy, mouthy, and think you know it all?
    Yes! This is exactly my problem. Sometimes I wonder whether I would be better off as one of the many students in my course who do not speak a good scope of English and act more like flies on the wall than students ready to learn.

    Quote from BluegrassRN
    I found that if I only spoke up once every three times that I had a question, I came across as less aggressive, less prickly and less annoying than if I asked every question that popped into my head. Basically, FILTER, FILTER, FILTER was my mantra, and it served me well.
    This is great advice and something I think will be really helpful for me, thank you! I'm going to write it down and keep it in my pocket whilst on clinical to consistently remind me!

    Quote from BluegrassRN
    Even a less than perfect clinical experience teaches you a lot. Don't forget that.
    I'm certainly not looking for the perfect clinical experience, if there is such a thing. I'm just trying to find a way to be a good student, learn and not step on any toes in the process. For me, this is so much harder than it sounds. Sometimes I wonder what is wrong with me... I mean, all the other students pass their placements no problems, so it can't be that hard, can it?

    Quote from BluegrassRN
    Keeping your head down is not defeat or a time waster. Observation *IS* important. So is working things about on your own, instead of asking about them. Respect for the patient and nursing staff is also an important aspect of your education, and although you wish the world to revolve around you, it actually doesn't (I still struggle with this concept...).
    I certainly don't think that observation is a waste of time. This is how you learn, especially in the beginning, right? I also think that respect for the staff and patients is crucial in forming a good working relationship with everyone on board. I guess it's the world revolving around you part I struggle with... I don't expect to be the centre of everyone's attention or the concern of all the nurses on the ward. I get that students are often just an extra burden on the ward and get in the way and I would really hate to get in the way. I try not to, I really do. I guess it's an intricate balance between observing, practicing skills/being involved and not treading on any toes in the process. This is what I find so difficult.

    Thank you so much for your feedback.
  5. by   AmericanChai
    Just like in other areas of life you get good people and bad people. I am just in Block 2 so I don't have a huge amt. of clinical experience yet. We did 6 weeks last semester in different types of care settings.

    I too am a very outgoing, friendly, curious type of person. It's hard for me to just sit there and act dumb. Instead of choosing a pt, I choose the nurse in charge of my pt. I start by asking her about something I notice she's really good at, how can I learn to be good at that, too. Usually that makes her more open to having me around. I give my assigned nurse breaks from me to catch up on charting and stuff, and try to take my lunch when she's not on lunch break to again give her some time "alone."

    What also works is to show I'm willing to do the grunge work. If someone needs cleaning up, I'm the first one to step in. I don't mind doing nursing assistant work because it helps me to learn to assess people. I would maybe never get a chance to look at someone's skin quality until I am able to see all of them undressed during a bed bath. Then I can sneak in a quick assessment. When the nurses realize I'm willing to get my hands dirty they seem to welcome me more into their unit.

    When I'm on a floor of hands-off, not so friendly nurses I escape into the patient's rooms and talk with them. Usually the pt is only too happy to tell you about their health issues, family, social life, etc. and what they wish would be different about their nursing care. They are flattered that a person would be so interested in them. ;-)

    There was a time when some tenseness was happening on my pod due to a pt. family issue, and it affected the moods of all the nurses. A social worker was brought in. I sensed that I needed to stay out of everyone's way for a couple of hours, so I literally went room to room asking pts if they needed anything, and keeping busy that way. And then talking to the pts in the process. Or, I find a pt who needs to go elsewhere for a test/procedure and I ask if I can go with them to learn more about the procedure.
  6. by   BluegrassRN
    It sounds like you have the tendency to over-think things. I get that, as well. It's just an effort to understand as much as possible; it's okay.

    You'll do just fine in your clinical experience. You'll misstep at times; everyone does. It's okay. Every misstep, every mistake, every poorly phrased communication is a learning opportunity. I tend to over-analyze my day as I'm on my way home form work. I always make myself think of what I've done well, in addition to what I've done poorly, what I could have done better. This is what I do to help me become a better nurse and coworker. Just a suggestion, it may be helpful for you, it may not be something you need.

    Good luck with your clinicals!
  7. by   netglow
    OP, here is something to ponder....

    Nursing school is really not set up for you to learn. That is, from other nurses.

    The learning comes on your own time and I mean without assistance. More often than not, you need to just do what needs doing to get thru school, no more, no less. I think there are probably few places left where a student can actually learn the way nurses used to learn in the past -- which was more like an apprenticeship. This is very unfortunate, but it is reality. You will find that most everybody in nursing these days, just doesn't want to be bothered with an intelligent student. The majority pretty much just wish the gaggle of students on the floor would just go away. If you get lucky and get a "live" RN who does want to show you stuff, don't get in her way, and allow the teaching to happen. Don't ask her silly questions that throw her off her schedule, just let her teach, and take it in. Then consider yourself to have had a wonderful day.
  8. by   bloviate
    Quote from rachelgeorgina
    I'm currently a second year student and getting ready to go on my first clinical placement
    I often feel like the simplest way to just pass each clinical to keep quiet, shut up, don't ask questions and just watch unless someone asks you to do otherwise.
    and just plain pass.
    Yes. You are correct. Be quiet, don't stand out and pass.

    Give someone even the slightest opening and they'll exploit it.
  9. by   Zana2
    Look, think of a ward as a well (or not so well) oiled machinery. And you, the eager student, willing the clog to roll when it's actually meant to stop, poking your fingers through little holes when you shouldn't, staring dizzy at the whole thing and not knowing where it's meant to start and where to end. Got that picture in your mind?
    Now. What's the machinery for? What does it do? An oncology floor.
    Go to the clinic for a day or two. See the patients with the first complaints, see how the doctor responds, what tests they order, how they speak, etc. Read on the subject.
    Then go to the ward and see then getting ready for surgery/chemo etc. What do the nurses to? What's the schedule?(dr rounds, meds, meals, etc)
    Focus a day or two on wound care, then on meds, then on surgery (go see it if you can).
    Then post op care (choose a bit or two, don't go after the whole package, remember all those clogs with nasty sharp teeth? drains is always a good one, CV lines-even if you don't get to pull them out, learn about them, there are tens of hundreds of them, why choose a robinson over a redivac, how long do they stay on, when to change them, can you think of a method to disguise them, such as a nice bag etc, etc, etc, you get the picture)

    Basically, after you made a cup of tea for your mentor, tell her what the focus of the day is for you. There's plenty to learn about stuff even after you've been doing it for years. You're there for a 'taster', to get an idea, not to become proficient at any of that, it takes much longer than a placement.
    You've got the luxury of learning without the fright of losing your pin. Take bite sizes and focus on basics.

    Also, find out what's the best way for you to memorise stuff. It's all a jumble, and it's coming on your head like a ton of bricks. I will never forget what omeprazole is and what it does, side effects, everything about it, because this guy once draw me a picture of the stomach, complete with esophagus, explained to me how the reflux works, what happens when omeprazole gets in there, etc. I found that drawing really helps me, so I've been drawing ever since(badly, I hasten to add, but it makes sense to me). Keep a little notebook in your pocket and scribble quickly something new, if you get the chance later, ask more, your look it up yourself.

    When it all gets too much to you, choose a day of 'taking a step back' and performing 'menial' tasks. Dish out food, or clean the trolleys or something that doesn't require more learning. Pace yourself.
    Good luck.
  10. by   Up2nogood RN
    My psych rotation was with hospice and I was like huh? Until the first shift and I figured it out. I didn't learn or even use ONE nursey taskey thing but learned the most that rotation just by listening. I'm not saying that will be the case for you as a med onc floor can be extremely busy but sometimes you CAN learn excellent therapeutic comm skills from these nurses on this type of unit. And those skills are priceless no matter where you end up working! Good luck I hope you enjoy your next rotation, I love this population of patients it really helped me learn empathy and put some things in my life in a better perspective.
  11. by   creating_wellness
    In nursing school, I drew on my work experience in customer service at a restaurant. I would give this pep talk to myself to set my head straight:

    1. Get your stuff done quickly and quietly. You are there to pass nursing school, period. Put your school work first.
    2. THEN ask questions, and make sure you prepare first. Look it up.
    3. Do helpful nurse aid type stuff if there's down time.
    4. I practiced these phrases: "What else can I get/do for you?" "I'm a student nurse, here to help your nurse take care of you today." "I haven't yet seen [a certain procedure], could you notify me if there are any opportunities to observe today?"
    5. Clarify with the staff: what you can / can't do, how long are you there, what you'll do for the nurse who has your patients.
    6. Keep your enthusiasm and energy for learning, even if your fellow students call you an "overachiever" (like my classmates did... but hey, who graduated magna cum laude?? me!)

    Hope my pep talk works for you too! Good luck.
  12. by   HouTx
    This is a very interesting thread. I have been a nurse since the earth's crust was cooling, but I do have vivid memories of the same sort of frustrations as the OP expressed.

    It's best to keep in mind that the ultimate responsibility for the care of the patient rests with the bedside nurse and he/she is not about to turn anything over to a student without absolute confidence that it will be done right. Nurses cannot (morally or legally) delegate anything unless they are personally satisfied that the other person is competent to do the task. So - that nurse's degree of confidence (in you) is far more important than your own self-confidence. Let's face it, self-confidence is an ephemeral thing and may be unfounded -- few of us can be objective about our own performance or abilities.

    Previous posters have offered some very sound advice about interactions between the student and the nurse. What hasn't been mentioned is that the mere presence of a student can frequently increase the nurse's stress level.... in addition to coping with their own heavy workload, they have the additional burden of supervising a student, usually without any additional compensation.

    I also think it is presumptious to expound on the 'cut-throat' nursing 'culture' when you have only experienced it from the fringes. It will be interesting to see if you still feel the same way after you have shouldered the responsiblity for a while.
  13. by   emmalou*
    Hi, I replied to your post last year.

    Congratulations on making it to 2nd year! Good for you.

    Did you receive any feedback on your last 2 clinical placements? It would be a good place to start, by thinking about what you need to work on still and working towards those goals you discussed with your facilitators.

    I guess I am just going to reiterate the advice I gave you last year which is to continue being enthusiastic and proactive as that is a good way to be.

    Don't do anything outside of your 2nd year nursing student capabilities
    Ask questions in appropriate situations. For example, in the middle of an emergency situation - not a good idea. In the middle of a routine procedure - it's ok to ask a couple of pertinent questions. After all the fuss has died down and during routine nursing duties - even better
    Take notes
    Have a plan in place before you start, of procedures you want to observe, skills you want to learn, questions you might want to ask
    Utilise your facilitator during the placement
    Stick close to your preceptor to learn the routine and time management
    Recognise that you are not always going to please everybody. By being polite, friendly, professional you know you are doing the best you can, if some nurses are still unhappy with dealing with students this is their problem
    Give appropriate, professional feedback to your facilitator about your placement
    Learn from your mistakes
    Avoid judgmental perceptions about nursing students like bottom feeders etc, if that is what you think, that's how you'll come across, believe me when I say you will need to be strong to deal with all the challenging behaviour that comes your way. Think of nursing students as learning, not stupid which is sometimes what you get called
    Sometimes it is a good idea to keep your head down - I can tell you when or whatever but you need to develop those skills of perception and understanding non verbal cues which is so important to being a nurse - this will happen over time

    I get the feeling you need a bit of reassurance still and I'm happy to give it but honestly, what you need to do is reflect on your past experience, be honest with your shortcomings and all you still need to learn, and recognise that this is an ongoing process.
  14. by   TrishJK
    Hi Rachel

    Zana2, HouTx and Emmalou have said more useful stuff than I could think to say. I went back and checked out last year's comms. You got some t'riffic advice there, too. So, as requested, here goes again - apologies to the three above - you have probably already said it:

    1. Remember the universe wasn't created in one semester. Slow down. If you run the whole time (from experience to experience) you won't really appreciate any but the most shocking/toe-stubbing moments. And, as you discovered last year, your metaphorical charging around upsets the locals.

    2. Keep a small notebook in your pocket so that when you feel that almost uncontrollable urge to interrupt with your oh-so-important question you can consider stepping away and jotting it down for reflection/research and/or later clarification with an experienced nurse. This will depend on the situation and all those variables already identified. Learn how to exist in the moment without seeking validation from others that you exist.

    3. You are the future of nursing. You are an important person. You are a valuable person. You are being given a huge privilege by very sick people and very hard working nurses - the opportunity to learn from others' experiences and to practice so that you can make mistakes safely. I applaud your desire to be as good as you can be. Regard this semester as an opportunity to hone your judgment skills.

    I sense your fear that you will receive more criticism than praise - and that this is your personal valley of the shadows. You have a huge hunger for approval. If you are not careful, it will continue to be your undoing - in nursing, in life, in general... Learn to make a steady, quiet inviolable centre, Rachel. Learn it sooner rather than later - and spare yourself this continuing world of hurt. (Consider signing on with a private psychotherapist who can help you to build it).

    People will not remember what we said. People will not remember what we did. People will remember how they felt when they were with us.

    Sometimes the best we can be is quiet and present for someone else - learn how to be quiet, Rachel - so that you can really learn what's going on around you. If you can really learn what's going on and then respond appropriately, you will make the kind of difference that people remember because it mattered (and coincidentally, get the kind of recognition that you crave.)

    When I was an oncology patient I felt very, very physically sick. Early on after my surgery, if my oncologist had stood at the end of my bed and said "You're cactus, babe." I would have said "Thank God." That's how physically sick I felt. There was a young nurse there who was assigned to look after me. She thought it was all about her. She had no idea that I even existed as more than a praise and gratitude machine for her. She spoke loudly, she moved loudly. Her keys rattled loudly. She smelled loud! She bristled with a sense of dramatic self-importance ("Look at me - I am Flo Nightingale reincarnated. And I am sexy - just like those gorgeous nurses on tv.")

    If I had had the energy I would have told her to go away. If I hadn't been scared that the quality of my care would deteriorate even further, I would have told her to go away. I dreaded hearing her coming. She didn't notice that I was in pain and too sick to say so. She didn't notice that the sun was reflecting off a picture hanging on the wall right into my eyes and I was too sick to turn over without help. She didn't notice that my mouth was dry but I was too sick to sit up to take a drink. I told her I was lying in a puddle of urine and she was hugely irritated that I wanted her to change the sheet. I used the very last of my energy to ask her to wash her hands when she tried to change my SPC without doing so first. She stormed off in a huff and I didn't see her again - thank gawd!! I will never forget her - and I love to tell the story of her complete incompetence. She made me feel that I didn't matter; that I was a nuisance. She terrified me. If I ever see her again - I will happily tear her a new a-hole.

    Good luck, Rachel. You can do it.