I'm embarrassed. Almost all of my clinical was shadowing, until I started doing mental health. Then I was alone with a patient.
I can't imagine a clinical scenario in training where a student could possibly provide the actual care for multiple patients. The instructor would have to be literally right there every minute.
I simply don't believe that any student provided hands on care for more than one or two patients on a shift. There would be nobody to observe you.
Unless you had a one on one instructor.
I can't imagine what this program would cost. It would be completely unaffordable.
I don't see a student "totally responsible for 6 patients"
I am glad that student RN's have much more responsibility now. They get more clinical practice. But it does cost more.
NP students typically mostly shadow.
The student is then responsible for the huge jump from school to actual practice.
So we have some of these hilarious but sad questions from people with no acute RN experience, then they get their FNP, and they think they are qualified for the ICU?
I'm embarrassed. Almost all of my clinical was shadowing, until I started doing mental health. Then I was alone with a patient.
I can't imagine a clinical scenario in training where a student could possibly provide the actual care for multiple patients. The instructor would have to be literally right there every minute.
I simply don't believe that any student provided hands on care for more than one or two patients on a shift. There would be nobody to observe you.
Unless you had a one on one instructor.
I can't imagine what this program would cost. It would be completely unaffordable.
I don't see a student "totally responsible for 6 patients"
I just do not believe it.
There are (or at least used to be) a lot of programs where, although a few aspects involved shadowing--such as OR observation experience--the rest of the clinical involved increasing levels of managing all aspects of bedside care. It was the opportunity to put your care plan into action in addition to whatever else was going on.
Along with having formulated a care plan, each week SNs were allowed to perform those parts of hands-on care that they had successfully demonstrated in lab. Usually the first live opportunity at a particular skill was observed and assisted by the clinical instructor and if performed appropriately then the SN was subsequently able to perform this without the instructor, with agreement from the patient's assigned nurse. Little by little you gained the ability to do most of whatever your patients needed.
The final culmination of everything was learning to manage an entire assignment during a capstone experience, paired with a single dedicated RN employed at the clinical site. My preceptor was fantastic, allowing me to do every skill that arose from our assignment and was either with me or was coming around behind me checking everything else I did, too. My assessments and charting were double-checked. Phone calls to providers were accomplished with the preceptor standing right there and then verifying any orders I took, which were then processed by me and co-signed by preceptor. Hands-on items (other than ADLs) were directly observed by preceptor. Report was given by me with preceptor present. Preceptor was around for most of what I did; some might find that stifling but my opinion is that it beats a situation where the preceptor goes off and does a thousand and one little things that the preceptee never knows about to hold things together. And at no time was the assignment loaded because "there are two of you" (one of the many benefits of attempting this feat of managing an assignment while still a student as opposed to an orientee).
As soon as I finished I immediately secured a job in a huge and regionally sought-after place, same type of unit. My orientation there was not stress-free of course, but was trouble-free. I can hardly even imagine some of the stuff I read about now.
As far as whether I would fare as well today, I doubt it. But then, it wouldn't matter because I wouldn't even be interested in today's scenario to begin with.
“Totally responsible” is probably not a good description. Back in the day clinical groups were small, maybe 4 students, so assuming a large part of the care for the patients assigned to us (usually 4) was entirely possible with the assistance of the RN also assigned. We were observed by our instructors and deemed okay to perform nursing tasks independently/with the assigned RN on a progressive basis. It started with the basics (VS, baths). Assessments were always done in tandem with the RN, documented by us and co-signed. First set of vitals we did but the remainder were done by the NA’s unless we were struggling with the skill. We would frequently team up with another student to complete “am care” which we could knock out pretty quickly. Complicated treatments (dressing changes, etc) were done with the RN or the instructor depending on what else was going on on the unit. Simple dressings, wound care, etc we could do. Once approved we could independently hang fluids, time tape the bag, draw labs, administer PO meds, and insert Foley’s, etc. Woe be to the student who didn’t do their I’s & O’s though. We were in clinical for 3 eight hour days/wk followed by 3 hours of class. The other two days were class days usually 8 hours long. We went year round with a one week break between terms. Still, even with all that we could do I wouldn’t call us completely responsible and the RNs would bail us out if we got in the weeds. In my three decades plus of nursing and precepting students I have never seen any student be entirely responsible for a full patient load. I think students who feel that they were capable of handling such loads as we have today may be suffering from “you don’t know what you don’t know” syndrome. But God bless their enthusiasm.
This is similar what my education was like (although I was never trained to do blood draws). I don't think I did any procedures (ie Foley insertion) w/out the precepting RN there, but as long as my instructor watched us do ONE, we could perform the procedure with the precepting RN.
"Totally responsible for" any number of patients as a student is a misnomer, because as an unlicensed person you cannot be. The RN assigned to the patients is totally responsible for the pts.
Specializes in Psychiatric and Mental Health NP (PMHNP).
I "mis-wrote" by stating full responsibility. My intention was to indicate that we were not just shadowing, but were assigned up to 6 patients per shift and we were expected to perform basic RN functions. We did have supervision from our clinical instructor. For example, if a patient needed a Foley inserted, we would have our clinical instructor there to supervise us as we inserted it, and help us as needed.
I was in an ABSN program. Our very first clinical day we went to our hospital rotation. The clinical instructor gave us a tour of the floor, showed us how to use the EHR, then gave each student one patient. We were expected to immediately perform very basic functions such as helping patients with personal hygiene, meals, and going to the bathroom. The clinical instructor came around to each student and supervised them taking vitals, performing basic PE appropriate to that hospital unit, etc. We were then responsible for documenting our work on the EHR under a special student password, but it went into the patient's real chart after being reviewed and approved by the instructor.
As the program advanced, so did our student nurse responsibilities. We were expected to be at the hospital by 6:30 am, in time to review our assigned patients for that day, listen in on shift report, and meet the RNs we would be working with. The number of patients assigned to us also went up over time. Here are the tasks I remember performing: vital signs, PEs, bathing, assisting with personal hygiene and toileting, patient comfort, meals, hanging IVs, medication administration, injections (insulin, vaccines), catheter insertion, documentation, giving report to RN and instructor, intake, discharge. Our clinical instructor had a schedule so she could supervise each student give meds, for example, as well as the other skills. We were to ask our clinical instructor if we needed help first, and if she couldn't help, then ask an RN. This was a few years ago, so I can't remember everything. One of my rotations was on a neurology unit. If a patient needed a neuro check every hour, we were expected to do it and document it.
During the ob/gyn rotation, I was present at multiple births, assisting the laboring mother with comfort measures, assisting the nurses, nurse midwife or obstetrician with the actual birth, monitoring fetal signs, etc. I learned to check the fetus vital signs during labor, perform US of pregnant women for maternal routine checks, etc. We also helped care for newborns - bathing, assisting new mothers with breastfeeding, giving infant vaccines, etc. Our clinical instructor rotated around the students so she could supervise each student as they performed these functions.
I had 2 psych rotations: 1 on an adult locked schizophrenia ward and 1 in a children's day hospital with some time also in the general inpatient children's ward. On the adult unit, there was a group of us students. We came in early for the initial morning review of the patients led by the NPs. Then we went out on the floor and circulated, assisting patients. We took turns taking vital signs. Under supervision, we took turns with medication administration. We had assigned exercises of interviewing patients as part of our learning. We also developed and lead group sessions. We had to document all of our activities in the EMR and our instructor had to review and sign off on all of it.
My final clinical rotation the psych children's day hospital, which was awesome. I was the only student. There were 2 RNs, a psychologist, an MD psychiatrist, and residents who rotated in and out. I sat in every morning on the case review, where all patients were reviewed with the RNs and providers and was expected to contribute as appropriate based on my observations. Every morning, I took all the vital signs and recorded them. Then I circulated among the patients, observing, helping and so forth. We ate lunch with the patients (free lunch yay!) and supervised the kids. I learned to lead group and designed groups and activities, approved by my RN preceptor. She also taught me to perform intake, transfers, and discharges - of course she reviewed all of these. I'm sure I had to write some papers and stuff. I must have added some value, as when I was done with my rotation, the psychiatrist said, "Can we get more students? It's really helpful!"
I also got observe and help out in the ECT unit for one day. First, I observed, then the RN taught me how to help prep the patient, take vitals, then after the doc administered the ECT, take the patient to the recovery area, take vitals, monitor LOC, etc etc. I must have done something right, because they invited me to come back and help if I wanted.
My point is that at the end, the students were hands on performing these actions and were responsible for a group of patients. The clinical instructor or an RN supervised when we did things like insert a catheter, administer meds, etc., but we actually did perform these skills with our own 2 little hands. We were evaluated on our ability to prioritize and manage the care of multiple patients on schedule, perform the skills and tasks correctly, alert the instructor or RN of patient status changes when appropriate, document the same, give report, and so forth. In addition, we were evaluated on our patient and family interaction and education skills.
Overall, I am happy with my nursing education and believe it was high quality. Honestly, I don't know what else the school could have done. Were we great at these skills upon graduation? Of course not, but at least we had performed the basics and it was a good foundation.
The school also had an excellent career adviser who made sure everyone had a good resume. We had a couple of job fairs that were packed with hospitals recruiting new grad RNs from across the country. We are also informed of RN residency and fellowship programs at local hospitals we could apply for.
Everyone in my BSN cohort either got a job shortly after graduation and passing the NCLEX or went directly into the NP program.
We would call the instructor to pass meds, and totally take care of one patient, then increased our patient load through the program to 4 patients. We pretty much did everything. If we did a foley or IV we had to have the nurse or the instructor with us. We would just go to the instructor, tell her the med, what it was for, yada, yada, then we would just give it ourselves. My last semester I was taking care of 2-3 step-down patients by myself basically. I had a fantastic basic nursing education at a community college for around $7,000. It was incredibly competitive to get into. I had a 4.0 on my pre-reqs and a perfect score on the HESI before applying and I STILL had to wait one extra application cycle (you could accumulate points for just applying and waiting a "round" of applicants) before getting in. I did IVs, blood cultures, foleys, NGT, etc.
I just graduated last year from an ABSN program. Our clinicals varied widely, depending on what specialty we were in AND what site we happened to be assigned to. When my group (6 students) did med-surge, we had two 12-hours shifts each week, and we really did a ton. It started with just bedpans and vital signs, but by the end of the semester, the RNs had gotten to know us, so we were really responsible for quite a lot. Was it a “full load”? No, of course not, but we were certainly doing dressings and foleys and hanging IV bags on “our patients” (3-4 typically)
Another group, from my class but assigned to a different hospital, said they did CNA tasks they entire semester, so it was luck of the draw.
When my med-surge group moved to pediatrics, yes, we were basically standing around and occasionally giving an oral med. We didn’t even really assess in pediatrics.
I am glad that student RN's have much more responsibility now. They get more clinical practice. But it does cost more.
NP students typically mostly shadow.
The student is then responsible for the huge jump from school to actual practice.
So we have some of these hilarious but sad questions from people with no acute RN experience, then they get their FNP, and they think they are qualified for the ICU?
Hi Oldmahubbard-
I’ve followed your posts for a while and really respect your opinion and experience. It seems things have largely changed since you were a student! Here was my experience:
BSN- I graduated with my bachelors (non-nursing in 2006) and did an RN diploma program (12 month program which eventually became a BSN- many pre-reqs required). We had extensive clinicals 2-3 full days a week for 48+ weeks working alongside a nurse WITH a clinical instructor for 4-8 students. I was well prepared to enter my new grad orientation in a pediatric trauma center ED.
FNP- I recently completed my MSN with Georgetown. I had NO shadowing. Everything was direct patient care with a preceptor, with a focus on building up my skills in accordance with where we were in the program. First semester of clinical was all well-person visits (HPI, physical assessment), second was episodic (acute visits, with problem-focus treatment plans), third was chronic care (addressing all of the previous, plus mgmt of chronic conditions), all leading to fully managing a 10-13 patient case load. I start a new job next month. I may be nervous (because who wouldn’t be?!) but I KNOW I am well prepared to provide outpatient care.
So, as to your point re: training. For both RNs and APRNs, there is variability in programs. But choosing a good program can lead to adequate clinical experience. Yes, it is not cheap to do- but neither are med errors. I’d argue that the problem is diploma mills producing “graduates” and employers unable to provide sufficient support from experienced staff to help the transition.
FNPs working in the ICU is not a problem with FNP training- it is a problem with going OUTSIDE the scope of training.
Physician education and training versus nurse practitioner education and training. Physician clinical hours versus NP clinical hours. Anyone can research this.
In my state NPs' have practice restrictions and are supervised by physicians.
Specializes in mental health / psychiatic nursing.
On 10/16/2019 at 3:12 PM, Oldmahubbard said:
I am glad that student RN's have much more responsibility now. They get more clinical practice. But it does cost more.
NP students typically mostly shadow.
The student is then responsible for the huge jump from school to actual practice.
So we have some of these hilarious but sad questions from people with no acute RN experience, then they get their FNP, and they think they are qualified for the ICU?
My own school experience was different from yours. I went through an ABSN program clinical began starting with minimal patient contact and lots of lab and simulation the first term, and by the end of the program during my practicum I was taking 5-6 patients (usually the most stable) on a high acuity adult inpatient psych unit and providing the vast majority of care with a 1:1 RN preceptor and a clinical instructor on site (overseeing 5 of us at the hospital). The RNs and manager on the unit all reported that they liked having myself (and one other peer) because it was like having extra RNs on the unit and really wanted to hire us, unfortunately hospital policies got in the way and it didn't work out.
In my PMHNP program we had one year of didactic followed by jumping into clinical. I had 3 clinical rotations, 6 months of peds, 10 months of community mental health, and 6 weeks of inpatient. In each setting I had a brief period of shadowing preceptor followed by listening and scribing while my preceptor worked with clients, then me working with clients with preceptor present, then me working with clients with preceptor in another room (often with their own clients) and me giving a quick ~5 minute report and treatment plan to preceptor at end of session for approval. Even though I couldn't sign for anything my preceptors let me use the EHR and put in lab orders and pharmacy orders, referrals etc which they would then either (copy, e.g. pharmacy orders) into their own order or counter-sign depending on facility policy. I went through a program which finds preceptors for students and which offers perks (though not pay) to preceptors and in which faculty made regular contact with preceptors to evaluate our progress.
It wasn't a perfect program, but I did learn a LOT and my own transition to practice suggests I was reasonably well set up to dive into independent practice on graduation. I've started working as a PMHNP on a medium-acuity forensic unit and have been expected to hit the ground running. It is a good work environment that is experienced in on-boarding new grads and which has a lot of resources and experienced colleagues to consult, but no one is actively holding my hand and I have been managing a full panel independently since my second week on the unit. (First week was orientation to unit, unit staff, patient population, continuing to step out for on boarding meetings, and starting to accept the panel I was taking over). While I certainly don't know everything, and will have some extra support (which is for all new providers regardless of background) for first 6 months I feel surprisingly comfortable with the transition and have received positive feedback from my supervisor and from unit staff on my work so far.
Physician education and training versus nurse practitioner education and training. Physician clinical hours versus NP clinical hours. Anyone can research this.
In my state NPs' have practice restrictions and are supervised by physicians.
To clarify, I am glad that I live in a state that restricts NP practice. My family sees Board Certified Internal Medicine physicians for their primary care.
Specializes in Psychiatric and Mental Health NP (PMHNP).
My NP program had very little shadowing. For example, I had a rotation in a busy Urgent Care. My preceptor let me shadow the first day and also had me learn how to use the EMR. Starting with the 2nd day, she had me see patients by myself, take the H&P, perform PE, develop DDx, then my recommended treatment. I would go give her report, then she would come in and briefly see the patient and confirm if I was on the right track or not. After a couple of weeks, she taught me how to e-prescribe with the EMR. She would check my rx before allowing it to be sent. By the end of the rotation, I was functioning pretty independently, seeing patients by myself, doing the charting, etc. She checked everything before it was signed off. When the chance to do procedures came up, she'd have me watch one first, then do them under her supervision after that.
Specializes in New Critical care NP, Critical care, Med-surg, LTC.
In my ADN program we were on a tiered system for our clinical. By the fourth semester I had five patients with my co-assigned nurse and I could complete tasks independently of my instructor (except med pass) as long as I had already been signed off. For example, I had been signed off on Foley insertion so if my patient needed a Foley I could find another student to do the two person safe insertion checklist without my coassigned nurse or instructor. Usually, though, the nurses were happy to be in there because we were still saving them time by doing the intervention, they were there for the safe checklist and moral/technical support. We functioned more as PCTs, taking care of vitals and patient needs like assisting with toileting, washing, etc. But we were responsible for knowing the pathophysiology of what's going on and the medications and treatment plan. By the time we finished our community college program, we were mostly prepared to hit the ground running in a new grad residency or nursing orientation. Our community college program is known for putting out nurses that can quickly transition to the floor because we have some experience with time management of multiple patient assignments. Granted, in the semester we probably only passed meds on five patients 2-3 times because there was only one instructor with eight students.
In my current NP program I'm working with a hospitalist. After one day of a shadow-type experience, the routine has become that I see a patient first and then write up my full HPI, assessment and plan. My preceptor does the same and we compare at the end. The only part I don't do is enter the orders and note into the computer, but I'm pretty well versed in that particular computer system so I'm not too worried about that part. There are not many interventions being performed by the hospitalists in my hospital, so I'm not doing much skill stuff, but I'm focusing on assessment, documentation and coming up with a treatment. It's been a great experience so far.
Oldmahubbard
1,487 Posts
I am glad that student RN's have much more responsibility now. They get more clinical practice. But it does cost more.
NP students typically mostly shadow.
The student is then responsible for the huge jump from school to actual practice.
So we have some of these hilarious but sad questions from people with no acute RN experience, then they get their FNP, and they think they are qualified for the ICU?