8-month nursing and lacking skills

chris_at_lucas_RN, RN · Mar 18, 2005

Hi. I graduated 8 months ago from an accelerated BSN program. This is my second degree and second professional career. The problem I'm having is that, while I'm book smart, I lack clinical skills.
...what I'm realizing is, at least where I'm at, the job consist mostly of case management. I feel like I'm not getting any clinical skills. Some days I feel like I'm working fast food.
...I rarely put in an IV (done it only 4 times) or draw blood. ...some IV team nurses tell me they don't want the patient "poked too many times".... I've not put in any NG tubes, no caths on women, and there has been no training on reading the telemetry strips (in fact, none of the nurses on my floor know how to do this even though we are considered to have the most heart patients and we have tele monitors at the nurses station...tele is monitored down the hall by techs--emphasis mine[chris_at_lucas_RN]).
...I am now a little nervous about the fact that I haven't done a lot of things that students from community colleges get trained to do.
Any advice? I plan to keep my head up, have a good attitude and not be overtaken by insecurity.
...the sense of resentment I have experienced from some nurses who started out as CNAs and worked their way up to RNs or LPNs; I have felt, only from some, that they scoff at my lack of physical skills training. In fact, there is a long-standing belief that the nurses turned out into the community by the community college here are better trained than the nurses turned out by the university. ...one LPN that I have to cover, who has been a nurse for 15 years and who I absolutely respect in terms of her clinical judgment and skills, is extremely rude (actually, she's downright mean) to me. I've even asked her, if she wouldn't mind, to please share her knowledge and experience with me because I'd like to learn from her. She only glared in response.

Man, am I glad you wrote. This is the first time I have posted about my experiences as a new nurse (can someone please tell them that a GN doesn't have the RN yet, and once you have the RN, you are not a GN????)

I have read that nurses' first jobs are often pretty awful. And now I know why, at least I know what my experiences have been.

I started out on a tele floor. (I should say that this is my third degree, my second license, my second profession and, well, you get the picture.) I was assigned a coach who thought it was OK to reuse an IV cannula that had been tried on the patient five minutes before (by me), and laid on the bedside table since. Hello? Can we say "asepsis?" I never saw the woman do an assessment before giving meds. She never signed off on the strips on her patients (and when I went to do so and actually looked at the strips, she said, just sign here, here and here; the techs know what they are doing!). Oooookaaaaay......

Coach #2 I had only one day on my way to coach #3. I should mention that all three were foreign trained nurses (I'm not going to specify which foreign nation, not interested in getting flamed). #2 was demonstrating how to speed up my assessment paperwork (all on computer) by not looking at or touching a patient in the process. (Magic maybe?) The patient in question was a diabetic lady who had had an "optical stroke" (family's term). She was "legally blind." Her pupils were blown, irregular and did not respond to light. (I actually looked, with my little flashlight.) #2 efficiently typed in that the patient's pupils were 3mm and reacted briskly.

By that time all I knew was, I didn't want to be a nurse like that. The coaches (if you can call them that) continually pressured me to work faster. The educator (trained here) kept reassuring me that I had what it takes to be a good tele nurse, reminded me that I had done very well on the PBDS, etc. (Unfortunately she had had a "cardiac event" and was recovering from a stent placement at the time of the switcheroo.) The unit manager was educated in Canadian and Australian schools (close enough to native US training in my book), and was an exceptional woman who warmly encouraged me to "have fun."

The day I made my decision to leave was a good one for me. I had had enough signs that the mixed signals and just plain bad nursing I was being "coached" to learn were nudging me rapidly toward burnout. The nurse manager cruised by, asked me how my day had been (she really was a lovely lady and I miss seeing her), and I told her frankly that "it bit," and that I did not think this was a good fit.

Long story short (we wish, eh?), in my exit interview, the nurse manager and the chief educator gently informed me that as a GN (grrr) I lacked the clinical skills to make it in a fast paced hospital (not even just the unit, but the entire place, apparently), and further that (and I just love this) experienced nurses resent it when a novice tells them they are wrong. Man, I wish I'd had the spine to tell them that--I never did. Kept my mouth shut except when specifically asked by the educator. (But for her cardiac event, I might still be there. Oh, well.)

I'm in a better spot now, more consistent with my previous (and current) profession. I'm getting wonderful feedback from my coaches: they think I am organized, accurate, competent. They think I've been a nurse "for years" and are shocked when they find I graduate in August and passed boards in September. Oh, yeah, and the job came with a raise in pay and better hours. (Ha!)

So, here's my advice. I think you are right on to take another spot in a place where you can get some experience. Maybe you'll find you are more welcomed there. The second job may become your primary one.

If you are to cover for an LVN who is rude to you, recall that as the RN, you clinically supervise him/her. Part of your responsibility is to keep the team moving and flowing, and rudeness from a resentful underling interferes with good patient care. You might seek the support of your nurse manager--this is often the most diplomatic way of making a complaint. Paint the picture of your readiness to learn to supervise effectively, "I'm concerned that I am not meshing well with so-and-so; can you give me some cues for how to help him/her overcome the barriers between us?"

Don't worry about not knowing everything clinical. We just graduated. We aren't supposed to know everything, just enough to stay safe and keep our patients and colleagues safe. We are blank pages, ready to learn how nursing really works.

I also believe that your drive to hone your clinical skills will serve you well. Keep asking for help and support, ask the other nurses to let you do the caths, IV's, punctures, etc. They are often glad to teach! The techs might appreciate a nurse who respects their skills--take your lunch break sitting with them, let them teach you what PVC's look like, and bundle branch blocks, and junctional rhythms and pacers. See if your hospital has training courses on telemetry. You need that, if only to satisfy your own need to know. (Funny, it's our license, I think it behooves us to really know. But so many "experienced" nurses seem rather cavalier about that.)

As to degrees, you will find ADN's who resent BSN's and MSN's because they are booksmart but not clinically as good. BSN's look down on ADN's as not very polished. MSN's hopefully will be above that, but I've found some very, very arrogant ones, both on the floor and in the classroom.

Becoming nurses doesn't resolve our personality issues, and it does sound like some that you and I have come across in our short tenures as RN's prove that point. I'm for finding ways to get really good at this. You seem to, too.

Thanks for this thread! And your "plan" (above, in the truncated quote) is an excellent one. I'm adopting it as my own as well.

Good luck. Let's keep in touch here....

llg, PhD, RN · Mar 18, 2005

Becoming nurses doesn't resolve our personality issues, and it does sound like some that you and I have come across in our short tenures as RN's prove that point. I'm for finding ways to get really good at this. You seem to, too.

Oh... I LOVE that quote! I hope you don't mind if I say similar things in the future.

llg

chris_at_lucas_RN, RN · Mar 18, 2005

Oh... I LOVE that quote! I hope you don't mind if I say similar things in the future.
llg

I'd be honored.

SmilingBluEyes · Mar 18, 2005

Any advice? I plan to keep my head up, have a good attitude and not be overtaken by insecurity.
.

THAT would be the plan!!!!!!!!!!!!!!!!!! You already said it. Yes, the first year or two can be so tough and yes, there ARE "nurse eaters" (not just NURSES who do this either) out there. Stay strong. You WILL find your niche, and when you do, it will all come together. Don't change for anyone! Just be yourself and do the best you can. It will get noticed-----and some will be jealous. Heck w/them. Just stick to the plan and principles. Hang in there, we are here for you and you can vent to me anytime. :)

PennyLane, RN · Mar 18, 2005

Frogdog, you're right, you should be getting way more clinical skills at your job. Good for you for realizing this and taking a new job. I graduated in December from an acclererated BSN program and I'm working in a busy ED. I do all those things you mention and more. The nurses who are precepting me are great at their job and take it seriously. Oh, and it's fun too. Sometimes the docs aggravate me but I guess that's part of the job. On any given day I'll start 3-7 IVs (our techs often beat me to it), put in a few Foleys, do a zillion EKGs and interpret, usually I'm printing strips for 1-2 patients and interpreting, yesterday we were hanging Levophed, had 3 patients that ended up going to ICU, other days I'm hanging blood, starting heparin drips on acute MIs, etc. I'm also getting Med/Surg skills because our patients often spend hours and hours waiting for a bed upstairs. We have a lot of nursing home patients come in who have central lines, G-tubes, decubiti, etc. Come to the ER. It's great!

Antikigirl, ASN, RN · Mar 18, 2005

My first job I went through a preceptorship as part of my orientation. Three months! Got very lucky! I was able to have a preceptor with me for things I hadn't gotten a chance to do in RN school (sometimes those technical skills don't happen, I never found a colostomy patient even though I tried, so I was never able to work with ostomies...I finally did at my first job and was assisted with my preceptor, not hard, but I was very nervous since I had never seen one in clinicals let alone have to work with one!).

Once my preceptorship was done, I was on my own on a totally different floor. The nurses there seems against one another! NO one would help me at all! It was very sad, and well...had to learn on my own basically.

A very young BSN came to work with us (I am ADN) and I had much more technical skills than her. I wound up being the teacher for her because no one else would help her out either. We did it together, always helped one another, and had many good laughs and crys I will tell you. But the nice thing...we both found someone to depend on when times got rough! That really helped!

Not to mention that, she and I learned what eachother were taught in our different degrees and found that they weren't as much different as the timeline in which to do it.

I taught her how to cath, how to do a NG, how to do an IV..none of which she had ever done, and I knew she was scared to death. Naaaa no reason for that, I was there to help...that is what I do :). So after a few weeks she was doing things like a pro...she just needed some hands on was all...knew the motions...just needed to practice :).

Remember that you do know the steps, you just need clinical practice (heck, I had been doing things for 5 years and still needed to hone in on my skills...ones I don't do often).

And if you can find someone you really bond with...you may get as lucky as I and have a partner that can help when she/he is able! That was very very helpful and worth finding for me!

llg, PhD, RN · Mar 18, 2005

Any advice? I plan to keep my head up, have a good attitude and not be overtaken by insecurity.

It sounds like you have a good grasp of the situation ... a good plan ... and a good attitude. I think you will do fine in the long run. It may just take you a little while to find your niche and get comfortable in your new profession.

One word of caution ... from a nurse with 27 years of experience.

Becareful not to fall into the trap of defining yourself as a nurse in terms of the technical skills that you have mastered. You are a nurse because of what you know and the judgments you can make -- not because of some technical procedural skill that can quickly be learned IF and WHEN you have a job that requires them. Those skills that you use in your job will be learned. Those skills that you don't use regularly will either not be learned or fall by the wayside. Either way, it won't matter because you won't need them for your job.

People with less education and who cost the hospital (and patient) less money can be trained to do many of the technical skills. Other skills (such as IV's) are often more efficiently and more safely performed by people whose jobs focus on that skill exclusively. (Note Chris-at-Lucas's story about the incompetent "coaches" she encountered.) To have every RN performing every technical skill is not in the best interest of the patient for both financial and safety reasons. And besides ... no one person CAN be an expert in all things. Don't feel that as a nurse you have to excel at every aspect of care. That is not realistic and will only lead you and our profession down a frustrating and painful path.

Unfortunately, some nurses have an unhealthy emotional need to "put down" those who have more education and/or less experience than they have. Over the years, they have become very good at finding their target's weak spot and exploiting it to their advantage. You sound like the kind of person I would like to hire ... someone with a good head on her shoulders and a positive attitude ... someone who would be capable of learning whatever skills you needed to do your job well. That's what matters most.

A good employer will be willing to teach you the skills you need. I wouldn't want to work for an employer that wasn't willing.

Good luck,

llg

bbcewalters, NP · Mar 18, 2005

Triage RN_34

You sound like a wonderful nurse and I hope that I will have someone just as great to work with at my first job. I will soon graduate from an RN program. :confused:

Bobbi

CSLee3, ASN, BSN, LVN, EMT-P · Mar 18, 2005

Hi all, had to jump in here, hope I don't offend anyone,,just MHO....being a former EMT, LVN and new RN..I too have experienced many "higher than thou" types. Usually RN looking down on the cnas, lvn, etc. But not always....after completing a good LVN program at local community college, I was blown away to find out my fellow new nurses in hospital orientation that have never done Foley, NG, IV, etc. etc. I am talking about BSN's exclusively. The LVN's and ASN's in my hired group had done numerous "checkoffs" at their respective college. My question is how can a nursing program, regarless of the level, not require these skills to be performed in front of an instructor, not once but many times...Man what is going on here. I am not knocking BSN's...it isn't thier fault if the school didn't teach it. It just doesn't make sense. Almost all the hosptial managers and supervisors are BSN, MSN and do a wonderful job. They all paid their dues on the floor and in the classroom. But in my case, a lady and I were hired night shift medsurg (years ago). She had BSN , I was LVN, we worked same floor, same shift. We both had "mentors". I officially oriented 3 days and was cut loose. She was still in "orientation after 6 months" Crazy....I know,,, why..because she had no concept of total patient care, basic nursing skills...nice person, good nurse (now).....why did her university (which claims to be an awesome one) throw her to the wolves and not prepare her. The community college's of america are kicking butt in my opinion to address the nursing shortage. There are always exceptions I understand. So the aminosity I see at the hospital is usually asn's versus the bsn's. The Lvns hold their own and are worth their weight in gold.Did you know in most states like Texas, LVN have a minimum of 980 clinical hours....much more than most ASN or BSN programs...Treat LPN/LVNs good, they truely work hard for a lot less money. Sometimes I just wished I was still an LVN. Sorry for the Ramble. Hang in there all...we are in the same boat on the same team. We need to rework or teaching institutions and not each other.....Chuck RN, ASN

frogdog · Mar 18, 2005

"Becareful not to fall into the trap of defining yourself as a nurse in terms of the technical skills that you have mastered. You are a nurse because of what you know and the judgments you can make -- not because of some technical procedural skill that can quickly be learned IF and WHEN you have a job that requires them."

Thanks for saying this. I have to remind myself all the time! I had a doctor say to me one day, "you mean you're a nurse here and you've never put in an NG tube?" He tried to put it in himself, as well as two other docs, and never did get it in.

I also agree that when a hospital has specialty teams, like IV teams, the patients are safer.

"My question is how can a nursing program, regarless of the level, not require these skills to be performed in front of an instructor, not once but many times..."

I have mixed feelings about this statement. We did perform the skills (in case you didn't know) but not many times. I raised the skills issue many times with professors and they kept saying, "skills you'll learn on the job and within a year you'll be secure; we want you to have a good foundation in the rationale of treatments." (well, they didn't actually always use those words, but you get the drift...) I see their point when I see nurses hang a bag of vanc prior to getting the results of a trough. (However, I read some recent lit that states it's not really necessary to get troughs on vanc unless you've got someone in renal failure.) Or, when a nurse doesn't question an order to run a continuous infusion (NS) on someone with CHF. I'm talking about nurses who have any level of education, though, and that is where I have the mixed feelings. Plenty of ASN nurses are just as concerned with rationale as the BSN nurses, yet they also get the skills training. So, while I see the point of knowing the rationale behind something, I don't see the point in not providing more quality clinical experience.

Anyway, thanks for all your support. I truly believe that in any profession, but especially in a profession as stressful as nursing, we need to support one another and understand that we can learn from each other no matter one's background. IN FACT, my philosophy is to recognize the universal spirit within each person with whom one comes into contact (recognize the buddha within); in doing so, I rid myself of arrogance which only serves to distance and I open myself up to knowledge and experience that person has to offer.

llg, PhD, RN · Mar 18, 2005

[quote=frogdog

"My question is how can a nursing program, regarless of the level, not require these skills to be performed in front of an instructor, not once but many times..."

I have mixed feelings about this statement. We did perform the skills (in case you didn't know) but not many times. ...

Plenty of ASN nurses are just as concerned with rationale as the BSN nurses, yet they also get the skills training. So, while I see the point of knowing the rationale behind something, I don't see the point in not providing more quality clinical experience.

.

I cut out a lot of the quote to save space... but I think you can tell what comments I am trying to resond to.

Different schools and different types of programs have different strengths and weaknesses -- just like individual people. Perhaps you went to a school that was a little weaker in the teaching of technical skills than it should have been. That's life. I'm sure the programs that are great at teaching technical skills have their weaknesses, too. That's true of every field of study. Not every lawyer went to a "top 10" law school. Not every physician went to a "top 10" med school ... etc ... etc ... etc.

As a profession and as individuals, we nurses need to stop bickering about this and stop "sitting in judgment" of our colleagues who went to programs that emphasized different aspects of nursing. Some people go to programs that emphasize technical skills ... other people go to programs that emphasize physiology, etc. ... other people go to programs that provide them a strong foundation for leadership roles .... etc.

People need to get over that and focus on being sure that they have the skills needed to do their job -- and be willing to support those who need to learn some additional skills. That's true whether we are talking about technical skills ... or theoretical knowledge ... or leadership skills .... or research skills .... or problem-solving skills .... or financial management skills .... or educational skills ...... whatever.

Each and every one of us has things we are not terribly good at. We need to acknowledge that in ourselves and accept it in others. Then we can work on those areas that we to in order to improve our practice ... and we can support each other in that effort.

llg