How can I help educate floor nurses as a Hospitalist NP?

[Bumashes, MSN, APRN, NP]

Ok. I'm putting my cards on the table. Putting my money where my mouth is. My boss asked all of us, physicians and nurse practitioners alike, to give ideas on what we can do to help with the flow of patient care at my hospital. In my opinion, right now the biggest problem that we have is that well over half of the staff on each floor have less than one year experience as nurses. New nurses are training new nurses. It's horrible. They leave in droves, and who can blame them? We do not have much of an education system set up for them. The only specialty that has an actual educator specifically for it is the ICU. Everyone else is relegated to one educator who is overwhelmed. So the new nurses go through a kind of rushed two week orientation that includes their computer training, facility orientation, and a series of power points that are pretty much useless. Then they are put out on the floor for only a few weeks with their "mentor" before being cut loose. The reason for the rush is because of the severe shortage of nurses in the facility. It really is a terrible situation. However, I am willing to throw myself into it and help if I can.

So I told my boss that I believe that nursing education and orientation is the main problem with patient care and patient flow in our facility. He said he's going to speak with the system educator about possibilities for me to assist with nursing education. This is great because I love to teach clinical concepts. However, I am uncertain how I could be best utilized. I do not think that classroom time would be cost-effective or as educational as actual on-the-floor learning. What I envision is more of me going to a floor and sort of mentoring and guiding new nurses through their day. Maybe showing them how I look at things such as labs and how to prioritize. I worked as a floor nurse for two years and then an ER nurse for five years before I became a nurse practitioner. So I have a basic understanding of how these things need to be done, and I am not so far removed from it yet as a nurse practitioner that I cannot relate to them. But I am reaching out to you all to see if you have any ideas on what I could do as an individual to assist with this. We are a pretty large hospital. Our facility has about 550 beds that stay full. I work as a nurse practitioner hospitalist, so I see all of the nurses from the ER and on up through most of the floors. So they already kind of know me, and I am familiar with the layout of their work areas.

I am willing to do this on my days off as well. I really don't mind. It is a problem that has bothered me for a long time now. And I would consider it volunteer work to the betterment of the nursing profession to be able to improve the situation in my facility. There are many things, of course, that I cannot solve. Staffing ratios, pay rates, etc. But the thing that I CAN help with is the every day function and basic working knowledge of the average staff nurse. Now, there still are some experienced nurses on these floors. And I would like to incorporate them as well if I can. However, on some floors it is so bad that the most experienced nurse among them has only two years of experience on some days. And I know that floor nurses have a tough workload, so it is difficult for the experienced nurses to take time out of their already busy day to help train the newbies.

Just for an example of what I am talking about :

I asked for a JP drain to be pulled on a surgical patient. Unfortunately, the only nurse who knew how to do that was at lunch. So, I instructed the three nurses who were present on how to do this procedure. This is the type of thing that I envision would work best. Going to their floor and being a resource to them. As well as looking into their pts charts and finding teachable items. Not really sure if that is realistic or not. So please, if you have a suggestion, post it. I am open to almost anything. I really want this facility to get better. I love my job, and it makes me very sad that many of my floor nurse colleagues are struggling.

Things I see often:

Not knowing when to call the doctor/NP.

Not knowing what labs correspond to what conditions.

Procedural knowledge deficits, such as with the JP drain.

Prioritization-the ice can wait, but the BP med cannot.

Drawing labs out of an IV line that has had fluids running in it for days just b/c the pt asked why not.

Not knowing the appropriate nursing interventions for follow up: example is that if you give IV insulin then you need to actually RECHECK the pts BG (that was a new ER nurse).

So you see what I mean? These are kinks that usually get worked out with a normal 3 month paired orientation and some good solid experienced nurses around you. But here they are literally thrown to the wolves and have very little resources in the way of experienced colleagues.

So, please help?

Thanks everyone!

[mom2grace]

I would first meet with the veteran nurses & ask them where they need education. Then survey the new nurses about what they think they need. Give them what they want & add in what you think they need.

Definitely do it in real time on the floor. You could even set up a simulation on drains (for example) on the unit & the nurses could just stop by for 5-10 minutes.

[traumaRUs, MSN, APRN]

Okay my thoughts:

1. Don't do this for free! We are a valuable commodity to the hospital and even more so if you are helping to retain nurses.

2. Agree to do specific training at specific times throughout YOUR day on different floors.

3. Encourage the hospital to provide more full time educators - your idea seems like it is just going to add more work for you.

4. Revamp the orientation process - new grads need 4-6 weeks on the floor where they are not counted in the staffing matrix.

5. Again, don't do this for free!

[Bumashes, MSN, APRN, NP]

I wish I had the time to do this during my day, but I don't think I would be able to do as much if I did.

I would like like to be paid for it, but we will see about that one.

I am encouraging more educator positions and better orientation, but pretty much if it costs money, then they aren't going to go for it, which is why I said I would come in on my days off and whatnot. It really is sad.

[MelEpiRN]

Enlist the help of physicians who support nursing education. I have often found that they're the ones with the ear of the admins and can push for educational opportunities. (Heck it benefits them too to have staff that know what they're doing). The risk management people should also be able to trend problem areas and push for more education.

I really think that what you're doing, hands-on real-time education is so valuable (compared to healthstream classes nobody pays attention to or classes staff sleeps through).

Sounds scary and kinda exciting at the same time! Best of luck!

[Kooky Korky, BSN, RN]

Ok. I'm putting my cards on the table. Putting my money where my mouth is. My boss asked all of us, physicians and nurse practitioners alike, to give ideas on what we can do to help with the flow of patient care at my hospital. In my opinion, right now the biggest problem that we have is that well over half of the staff on each floor have less than one year experience as nurses. New nurses are training new nurses. It's horrible. They leave in droves, and who can blame them? We do not have much of an education system set up for them. The only specialty that has an actual educator specifically for it is the ICU. Everyone else is relegated to one educator who is overwhelmed. So the new nurses go through a kind of rushed two week orientation that includes their computer training, facility orientation, and a series of power points that are pretty much useless. Then they are put out on the floor for only a few weeks with their "mentor" before being cut loose. The reason for the rush is because of the severe shortage of nurses in the facility. It really is a terrible situation. However, I am willing to throw myself into it and help if I can.

So I told my boss that I believe that nursing education and orientation is the main problem with patient care and patient flow in our facility. He said he's going to speak with the system educator about possibilities for me to assist with nursing education. This is great because I love to teach clinical concepts. However, I am uncertain how I could be best utilized. I do not think that classroom time would be cost-effective or as educational as actual on-the-floor learning. What I envision is more of me going to a floor and sort of mentoring and guiding new nurses through their day. Maybe showing them how I look at things such as labs and how to prioritize. I worked as a floor nurse for two years and then an ER nurse for five years before I became a nurse practitioner. So I have a basic understanding of how these things need to be done, and I am not so far removed from it yet as a nurse practitioner that I cannot relate to them. But I am reaching out to you all to see if you have any ideas on what I could do as an individual to assist with this. We are a pretty large hospital. Our facility has about 550 beds that stay full. I work as a nurse practitioner hospitalist, so I see all of the nurses from the ER and on up through most of the floors. So they already kind of know me, and I am familiar with the layout of their work areas.

I am willing to do this on my days off as well. I really don't mind. It is a problem that has bothered me for a long time now. And I would consider it volunteer work to the betterment of the nursing profession to be able to improve the situation in my facility. There are many things, of course, that I cannot solve. Staffing ratios, pay rates, etc. But the thing that I CAN help with is the every day function and basic working knowledge of the average staff nurse. Now, there still are some experienced nurses on these floors. And I would like to incorporate them as well if I can. However, on some floors it is so bad that the most experienced nurse among them has only two years of experience on some days. And I know that floor nurses have a tough workload, so it is difficult for the experienced nurses to take time out of their already busy day to help train the newbies.

Just for an example of what I am talking about :

I asked for a JP drain to be pulled on a surgical patient. Unfortunately, the only nurse who knew how to do that was at lunch. So, I instructed the three nurses who were present on how to do this procedure. This is the type of thing that I envision would work best. Going to their floor and being a resource to them. As well as looking into their pts charts and finding teachable items. Not really sure if that is realistic or not. So please, if you have a suggestion, post it. I am open to almost anything. I really want this facility to get better. I love my job, and it makes me very sad that many of my floor nurse colleagues are struggling.

Things I see often:

Not knowing when to call the doctor/NP.

Not knowing what labs correspond to what conditions.

Procedural knowledge deficits, such as with the JP drain.

Prioritization-the ice can wait, but the BP med cannot.

Drawing labs out of an IV line that has had fluids running in it for days just b/c the pt asked why not.

Not knowing the appropriate nursing interventions for follow up: example is that if you give IV insulin then you need to actually RECHECK the pts BG (that was a new ER nurse).

So you see what I mean? These are kinks that usually get worked out with a normal 3 month paired orientation and some good solid experienced nurses around you. But here they are literally thrown to the wolves and have very little resources in the way of experienced colleagues.

So, please help?

Thanks everyone!

What is Admin like? Can you get them to give a longer orientation? And get Managers and Directors to work the floors instead of whatever else they are doing? At least for a while to get some staff trained up?

I applaud your desire to effect positive change.

[Kooky Korky, BSN, RN]

I wish I had the time to do this during my day, but I don't think I would be able to do as much if I did.

I would like like to be paid for it, but we will see about that one.

I am encouraging more educator positions and better orientation, but pretty much if it costs money, then they aren't going to go for it, which is why I said I would come in on my days off and whatnot. It really is sad.

Will you be covered by Workers' Comp if you are working for free?

[JKL33]

Ok. I'm putting my cards on the table. Putting my money where my mouth is. My boss asked all of us, physicians and nurse practitioners alike, to give ideas on what we can do to help with the flow of patient care at my hospital. In my opinion, right now the biggest problem that we have is that well over half of the staff on each floor have less than one year experience as nurses. New nurses are training new nurses. It's horrible. They leave in droves, and who can blame them? We do not have much of an education system set up for them. The only specialty that has an actual educator specifically for it is the ICU. Everyone else is relegated to one educator who is overwhelmed. So the new nurses go through a kind of rushed two week orientation that includes their computer training, facility orientation, and a series of power points that are pretty much useless. Then they are put out on the floor for only a few weeks with their "mentor" before being cut loose. The reason for the rush is because of the severe shortage of nurses in the facility. It really is a terrible situation. However, I am willing to throw myself into it and help if I can.

So I told my boss that I believe that nursing education and orientation is the main problem with patient care and patient flow in our facility. He said he's going to speak with the system educator about possibilities for me to assist with nursing education. This is great because I love to teach clinical concepts. However, I am uncertain how I could be best utilized. I do not think that classroom time would be cost-effective or as educational as actual on-the-floor learning. What I envision is more of me going to a floor and sort of mentoring and guiding new nurses through their day. Maybe showing them how I look at things such as labs and how to prioritize. I worked as a floor nurse for two years and then an ER nurse for five years before I became a nurse practitioner. So I have a basic understanding of how these things need to be done, and I am not so far removed from it yet as a nurse practitioner that I cannot relate to them. But I am reaching out to you all to see if you have any ideas on what I could do as an individual to assist with this. We are a pretty large hospital. Our facility has about 550 beds that stay full. I work as a nurse practitioner hospitalist, so I see all of the nurses from the ER and on up through most of the floors. So they already kind of know me, and I am familiar with the layout of their work areas.

I am willing to do this on my days off as well. I really don't mind. It is a problem that has bothered me for a long time now. And I would consider it volunteer work to the betterment of the nursing profession to be able to improve the situation in my facility. There are many things, of course, that I cannot solve. Staffing ratios, pay rates, etc. But the thing that I CAN help with is the every day function and basic working knowledge of the average staff nurse. Now, there still are some experienced nurses on these floors. And I would like to incorporate them as well if I can. However, on some floors it is so bad that the most experienced nurse among them has only two years of experience on some days. And I know that floor nurses have a tough workload, so it is difficult for the experienced nurses to take time out of their already busy day to help train the newbies.

Just for an example of what I am talking about :

I asked for a JP drain to be pulled on a surgical patient. Unfortunately, the only nurse who knew how to do that was at lunch. So, I instructed the three nurses who were present on how to do this procedure. This is the type of thing that I envision would work best. Going to their floor and being a resource to them. As well as looking into their pts charts and finding teachable items. Not really sure if that is realistic or not. So please, if you have a suggestion, post it. I am open to almost anything. I really want this facility to get better. I love my job, and it makes me very sad that many of my floor nurse colleagues are struggling.

Things I see often:

Not knowing when to call the doctor/NP.

Not knowing what labs correspond to what conditions.

Procedural knowledge deficits, such as with the JP drain.

Prioritization-the ice can wait, but the BP med cannot.

Drawing labs out of an IV line that has had fluids running in it for days just b/c the pt asked why not.

Not knowing the appropriate nursing interventions for follow up: example is that if you give IV insulin then you need to actually RECHECK the pts BG (that was a new ER nurse).

So you see what I mean? These are kinks that usually get worked out with a normal 3 month paired orientation and some good solid experienced nurses around you. But here they are literally thrown to the wolves and have very little resources in the way of experienced colleagues.

So, please help?

Thanks everyone!

I too think it's great that you want to help this situation, but have conflicting thoughts about how you can do that.

On the one hand, voicing your concerns carefully may help generate some motivation for change.

On the other hand - admin absolutely does know about this. Asking for suggestions about some other issue ("flow of patients") seesm like a move from a play book, doesn't it? They have massive turnover and they are calling far and wide for suggestions about what to do about something other than that? That is some game-playing.

As to your specific suggestion that you might offer inservices or real-time tidbits of info here and there...unfortunately these nurses have missed the opportunity to form the foundation and knowledge base that is usually begun during an appropriate (and supported) orientation process. Learning a random thing or two here and there when you happen to be around is nice of you to offer, but I'm not sure how much it will help. Sure, if you are there and can teach a thing or two (such as how to remove a JP drain) you should do that, but I sincerely don't think those things (alone) will put a dent in this problem.

This is an administration issue to its very rotten core. Their options are to get some educational support and floor support for these nurses ASAP. And that is it.

Sorry to be a Debbie Downer. This is unacceptable.

[Jules A, MSN]

Probably simplistic and based on personal experience n=2 but I'd guess this is a large teaching hospital with a fancy name. They love the new grads with alphabet soup as their title who they can pay $20 an hour and bully into thinking the current staffing ratios are even remotely acceptable. Gotta love it when the charge RN graduated two months ago, with their "masters" degree. Now throw in a strategic plan to fix this problem and they look even better, especially if the plan is spearheaded by someone willing to do it gratis. In my opinion focusing only on training rather than retention and appreciation of seasoned staff is the kiss of death.

[ruby_jane, BSN, RN]

Not knowing when to call the doctor/NP.

Not knowing what labs correspond to what conditions.

Procedural knowledge deficits, such as with the JP drain.

Prioritization-the ice can wait, but the BP med cannot.

Drawing labs out of an IV line that has had fluids running in it for days just b/c the pt asked why not.

Not knowing the appropriate nursing interventions for follow up: example is that if you give IV insulin then you need to actually RECHECK the pts BG (that was a new ER nurse).

First off, thank you for noticing and wanting to help. And being respectful.

The things that you detailed give me the heebie-jeebies.

Procedural stuff comes with time. Knowing when to call the NP comes with time. The rest of it...well, they should know that.

Share that list with the people who do training. Use those examples (identify problem, treat problem, recheck to verify problem was treated).

When I was a floor nurse I would have killed for a practitioner like you. Good luck!

[SpankedInPittsburgh, DNP, RN]

Yeah. Don't do anything for free. This is an institutional problem. I've heard quite a bit of good input here. You are one NP and cannot train a hospital full of nurses. However, a functioning education department and a cadre of veteran leadership can. Focus doing your job and in your role the best you can. If you take on tasks for free you become part of the problem and not part of the solution. Nurses tend to do this as a group we tend to become codependent in situations beyond our control and this leads to unrealistic expectations from us both by ourselves and by the group accepting the free help. Tell the hospital they need to address these issues (which really cannot be breaking news to them) and serve your patients the best you can. Sometimes you gotta let Rome burn so something better can be built on the ashes

[gemmi999]

To be honest, a lot of what you're detailing should be the responsibility of the preceptor and/or charge RN on the unit. I was a new grad to the ED and my preceptor is the one who worked with me on my prioritization, etc. A couple things to consider:

1) Most RNs know that the BP medicine has priority over ice--unless they're being graded on customer satisfaction and they're stressed out and worried about a bad HCAHPS score and what that will mean for their job. Maybe talk with administration about pressure placed on HCAHPS being detrimental to pt. care and if pt. care suffers--guess what, HCAHPS goes down!

2) Looking up pt lab values and "educating" the RN about what those mean--I can only imagine how frustrating I would have found this when I was a new nurse. It's a nice thought but do you really want the new RNS saying: "Well, I don't know what those lab results mean--I need to find that NP to do my work for me?" I don't think they would say that, but you're saying the inverse--"They don't know what the labs mean, I better just double check and make sure to educate them for their own good". Maybe I'm reading too much into this, but if I have a question about lab results, I can call lab, ask another RN/Charge RN or even call the MD.

3) Pulling blood from a line that had fluid running--that sounds like a general education point for the floor and lab--what to waste, when it's okay to pull (central line, etc) and when it's not. Maybe flyers in the restroom?

4) Regarding appropriate follow up--that's really hard to know how to teach/when to teach. If you're only there on the floor two hours a week, you're probably not going to be seeing a lot of opportunities for education. And honestly, it is one of those things that is learned best through experience. Maybe just tell the charge RN about what you know and let them follow up with the RN in question during their shift.

Lastly--don't do it for free! If the hospital wants to stay open they need to confront the realities of what they need to change. A NP stepping up and volunteering her time is at best a stop gap and at worst means that administration doesn't have to do anything. Set up some educational floor inservices about procedures; make sure the policy/procedure is well written and clear, and make sure the RNs know where to find it.

Speaking as someone who started in a facility like this, where I was asked to be charge with 8 - 10 months of ED experience because everyone else was newer then me, RNs are going to come, get their year (or less) experience and leave for a safer place to practice. Administration is going to have to change a *lot* of things to attract and retain experienced nurses.