New grads being rushed into "nursing maturity"

[PA_RN87, BSN, MSN, RN, APRN]

Based on several threads that I've read on here, and on my own personal experiences as a new nurse beginning my 4th month of experience, I'm seeing a general trend towards rushing new nurses into experiences, roles or responsibilities that traditionally are more "appropriate" for nurses with a little more experience. This coincides with hearing several stories by new nurses who were pushed off of orientation early, given a shortened or unstructured orientation, or no orientation whatsoever.

I would ask why the big rush to have new nurses function on the same level as nurses with years of experience, but I already know the answer - finances. They're paying you to work as a functional team member, and expect you to preform according to your payscale. Fine - I get that - but at what point do we cross the line where the costs outweigh the "cost benefits?" Pushing new nurses too quickly leads to problems on the patient side, and on the nurse side. Patient safety is put on the line by overtaxing a new nurse with extra patients, longer hours, or more responsibilities. Nurses are "burning out" quicker or quitting before they hit the 6 month mark.

None of these things are healthy even with experienced nurses, so I don't mean any disrespect for those experienced nurses who struggle with the same situations. However, new nurses aren't as "seasoned" and are more likely to make a mistake or burn out quicker.

Personally, I'm barely into my 4th month (including orientation), and I've been given more than the "maximum" patient load, expected to join committees, floated to 4 different units (despite being told new nurses aren't floated until after 6 months), and taken advantage of with scheduling.

Just opening this up for a general discussion. I'm interested in everyone's personal stories relating to the topic, as well as your views and opinions.

[elkpark]

It's not just a matter of the employer expecting you to function according to the "payscale" -- the employer is paying for your level of licensure. The fact that you hold a nursing license is supposed to mean, legally, that you are competent to function at that professional level. Long, long ago, new nursing graduates came out of school much better prepared to start functioning in clinical settings. Now, most new grads need (and expect to receive) extensive "orientation" (I put it in quotes because what we're talking about is really much more an extension of formal nursing education than it is an orientation to a new job) which is very expensive for employers to provide -- that's not the fault of the new graduates, but a lot of employers are getting fed up with having to pay to teach new grads stuff that the employers feel, rightly or wrongly, that the individuals should have learned in nursing school.

I think we're getting close to some kind of "tipping point" in nursing education -- even before the economy tanked, more and more healthcare employers were starting to post "new grads need not apply" messages with their job postings, and I think that trend is going to continue even after the economy recovers, until there is a real shortage again and employers are truly desperate. I think that nursing eduction has "thrown the baby out with the bathwater."

[LadyFree28, BSN, LPN, RN]

Elkpark brings up a great and important point. There are several studies relating to creating a "transition to practice" model program for EBP to meet the demands of newly licensed nurses to be brought up the "curve", so to speak. Currently I know of a few hospitals that have the set up of this model for years, another abandoned it (think this was a grave mistake), with mixed results in my area..some hospitals are better with this than others, IMHO; and I know of a program in CA, and in OH, where one of the studies is being offered.

In this climate, I believe it will be up to the new grad to combat the burnout to take up a nurse refresher course to help bridge the gap if they feel the need to learn more, even on top of the investment of their studies; however, with grads not entering the workforce immediately upon graduation and licensure, one has to willing on advocating for success in their career...even if it means taking a refresher course. They even count towards the CEU's for states that engage in these requirements. The ones in my area are EXCELLENT and area hospitals are very friendly in taking "graduates" from these courses. I am considering taking a refresher course if I choose to take care of adults, which I desire to reenter into. I am also a "new" nurse; and I will take advantage of learning and adapting to the demands, because I want to be successful in my practice.

My hope, and it seems possible with the transition to practice programs being piloted to EBP, that nursing education will change, and catch up with the ever broadening scope of nurses. We are truly a part of the healthcare team, and in most places, being in command of most responsibilities that were once held as exclusive to the physician.

[llg, PhD, RN]

Adding to what the previous posters have said (great posts, BTW) ...

I believe another thing that should happen is that we need to change the pay scales so that new grads make less money while they are on orientation and not "pulling their weight" on the team. That's part of the problem. Employers aren't willing/able to pay for the expensive on-the-job training required by new grads while paying them as if they were functioning at a full professional level. But so far, that idea has not been culturally acceptable within nursing.

I know that idea is controversial, but nurses can't have it both ways. If people want to be paid salaries close to what nurses with 2 or 3 years of experience make, they need to function at that level and "be worth it" to the employer. If they need 6 months to a year of special training, reduced responsibilities, etc., they have to expect to be paid less. Medical residents and fellows make considerably less than attending physicians, law firm associates make a lot less than partners, etc. New school teachers are on the same pay scale as experienced ones, but they are assigned their own classrooms on Day #1 with NO preceptorship time. Nursing needs to decide which model they want to use -- the one in which new grads are ready-to-go on day #1 and deserve a full professional salary ... or the one in which the new grads needs additional training and transition time and does not deserve a full professional salary. We can't have it both ways.

This idea is particularly pertinent because of the high number of new grads who plan to work in the first job for only a year or two before moving on to something else. Why should an employer provide a full professional salary + a lot of expensive education to someone not functioning at a full professional level who does not plan to stay in that job long enough for it to be a worthwhile investment to an employer?

We need to look at a new model ... with different pay expectations to match the level of responsibility new grads are prepared to take ... the type of training they need ... and the likelihood of their staying in their first job for a substantial period of time.

[Altra, BSN, RN]

Excellent posts, above.

Healthcare has changed. Acuity of patients across the spectrum of acute, subacute and long-term care is generally significantly higher than it once was. Healthcare culture and regulatory requirements now mandate considerably more intensive management of a patient's psychosocial circumstances than was once typical. It is entirely possible that we have reached that tipping point where pre-licensure nursing education is simply not enough to prepare new nurses to "hit the ground running". This is not without precedent -- newly licensed MDs are not "turned loose". It is understood that graduation from medical school and completion of the first phases of USMLE are not sufficient for independent practice.

The development of clinical judgement takes time and repetition. Maturity contributes greatly too, which is why I advocate for the BSN as a minimum educational point of entry. It is unfair and unproductive to expect a 20-year old to have the same ability to assume responsibility for self-learning and cope with the intellectual/emotional challenges of patient care that an older nurse brings to the table.

The foundations of this career progression (and the progressive pay structure that should accompany it) exist in the clinical ladder model. We need to use this model wisely.

And I personally think that nursing needs to stop pimping itself out as labor for hire, too, but that's a whole different thread. :)

[Susie2310]

The development of clinical judgement takes time and repetition. Maturity contributes greatly too, which is why I advocate for the BSN as a minimum educational point of entry. It is unfair and unproductive to expect a 20-year old to have the same ability to assume responsibility for self-learning and cope with the intellectual/emotional challenges of patient care that an older nurse brings to the table.

From reading these boards it appears that many current ASN/ADN students are older students with work/life experience and often have previous degrees, and that many ASN/ADN prepared nurses were older students with work/life experience when they received their training. This was also the case in the ADN program I graduated from 18 years ago. I don't see a persuasive argument for a BSN being required for entry in to practice.

[elkpark]

The development of clinical judgement takes time and repetition. Maturity contributes greatly too, which is why I advocate for the BSN as a minimum educational point of entry. It is unfair and unproductive to expect a 20-year old to have the same ability to assume responsibility for self-learning and cope with the intellectual/emotional challenges of patient care that an older nurse brings to the table.

I agree with Susie2310. I've taught in both ADN and BSN programs, and, in my experience over the years, ADN students were far more likely than BSN students to be older individuals with greater depth and breadth of life experience and general maturity. While I agree with the idea that modern nursing requires a greater degree of maturity and basic, general competence than in the past, I don't see how that connects to requiring a BSN for licensure.

[Gentleman_nurse, MSN]

What you describe is very common in the field of education. New teachers are often given a set keys and told good luck. As a result 50% leave the profession after 5 years. It's the tug of war between staffing and professional practice. Places that value professional practice will provide training and a gradual immersion process. It costs money and time upfront but the employer understands professional development is a long term investment. The staffing model just wants bodies to get the work done. A nurse is a nurse is a nurse.

[PMFB-RN, RN]

Excellent posts, above.

Healthcare has changed. Acuity of patients across the spectrum of acute, subacute and long-term care is generally significantly higher than it once was. Healthcare culture and regulatory requirements now mandate considerably more intensive management of a patient's psychosocial circumstances than was once typical. It is entirely possible that we have reached that tipping point where pre-licensure nursing education is simply not enough to prepare new nurses to "hit the ground running". This is not without precedent -- newly licensed MDs are not "turned loose". It is understood that graduation from medical school and completion of the first phases of USMLE are not sufficient for independent practice.

The development of clinical judgement takes time and repetition. Maturity contributes greatly too, which is why I advocate for the BSN as a minimum educational point of entry.

*** I think this position would have far more merit if we graduated new BSNs as competent practitioners who would be ready to take a full med-surg patient load with only a week or two of orientation. However we are not even coming close to that. New grads are almost helpless. None of the about-to-graduate students I work with have ever managed a 4 or 5 patient assignment. None of them are taught basic nursing skills in nursing school. I get students from two ADN, two BSN and one DE MSN program to precept. This has changed over the years. I clearly remember having to manage a 4 or 5 patient load the last semester of nursing school clinical. Four years SHOULD be plenty of time. IMO it is time for a massive change to nursing education.

[Not_A_Hat_Person, RN]

It's not just a matter of the employer expecting you to function according to the "payscale" -- the employer is paying for your level of licensure. The fact that you hold a nursing license is supposed to mean, legally, that you are competent to function at that professional level. Long, long ago, new nursing graduates came out of school much better prepared to start functioning in clinical settings. Now, most new grads need (and expect to receive) extensive "orientation" (I put it in quotes because what we're talking about is really much more an extension of formal nursing education than it is an orientation to a new job) which is very expensive for employers to provide -- that's not the fault of the new graduates, but a lot of employers are getting fed up with having to pay to teach new grads stuff that the employers feel, rightly or wrongly, that the individuals should have learned in nursing school.

The nurses of yesteryear got a lot more clinical training than more recent grads. Back in the days of hospital-based training, students staffed the second shift. They could hit the floor running after graduation because they'd been nurses in all but license for a while.

When I graduated in 2008, not only were clinical sites very hard to find, they put extensive restrictions on students. My program had 2 med-surg rotations. My first was at a rehab hospital; once AM vital signs and breakfast were done, there wasn't much for students to do until Glucose Smackdown at 11 am. One of my classmates had a complex med-surg rotation at a facility that didn't allow students to give non-oral meds. Another had a peds rotation at a hospital that got so few peds patients that the unit sometimes shut down. With one exception, we never had a Pyxis/Omnicel access, so we had to go to the nurses for everything, including tissues. If you weren't very aggressive about doing procedures, at a facility that allowed students to do procedures, you gave bed baths all day. Yes, bathing, feeding, and ambulating are basic nursing care, but that's not all nurses do, and it shouldn't be all they learn. A student RN needs to be able to function as an RN, not a CNA who occasionally gives meds.

I wish more schools used the one-on-one preceptor model for clinicals; it's really not the floor nurse's job to train students, and some are very bad teachers. Clinical groups at my school were 7 or 8 students per instructor; for complex med-surg it was 7 students on 2 units per instructor. It's hard to ask you instructor for help when you can't find them. I also would like to see more semester-long practicums (practica?), to make up for the lack of clinical training in school.

New grads don't know much about hands-on care because they don't have much clinical time, and they aren't allowed to do much in clinical. Hospitals brought the problem of poorly-trained new grads on themselves.

[LadyFree28, BSN, LPN, RN]

The nurses of yesteryear got a lot more clinical training than more recent grads. Back in the days of hospital-based training, students staffed the second shift. They could hit the floor running after graduation because they'd been nurses in all but license for a while.

When I graduated in 2008, not only were clinical sites very hard to find, they put extensive restrictions on students. My program had 2 med-surg rotations. My first was at a rehab hospital; once AM vital signs and breakfast were done, there wasn't much for students to do until Glucose Smackdown at 11 am. One of my classmates had a complex med-surg rotation at a facility that didn't allow students to give non-oral meds. Another had a peds rotation at a hospital that got so few peds patients that the unit sometimes shut down. With one exception, we never had a Pyxis/Omnicel access, so we had to go to the nurses for everything, including tissues. If you weren't very aggressive about doing procedures, at a facility that allowed students to do procedures, you gave bed baths all day. Yes, bathing, feeding, and ambulating are basic nursing care, but that's not all nurses do, and it shouldn't be all they learn. A student RN needs to be able to function as an RN, not a CNA who occasionally gives meds.

I wish more schools used the one-on-one preceptor model for clinicals; it's really not the floor nurse's job to train students, and some are very bad teachers. Clinical groups at my school were 7 or 8 students per instructor; for complex med-surg it was 7 students on 2 units per instructor. It's hard to ask you instructor for help when you can't find them. I also would like to see more semester-long practicums (practica?), to make up for the lack of clinical training in school.

New grads don't know much about hands-on care because they don't have much clinical time, and they aren't allowed to do much in clinical. Hospitals brought the problem of poorly-trained new grads on themselves.

Some places are putting restrictions due to "liability issues"...with a glut of old and new nursing programs, coupled with 50% of the hospitals remaining in a particular area after a transition over 20 years, it can be detrimental to the nursing student, hands down, at least in my area.

Since I was well aware of my market, I looked into programs where they had documented relations with certain area hospitals. My university was invited into health systems that had nursing programs (BSN), and were were treated equally: access to computer, Pyxis, etc. Real hands on, units taking you under the wing, observation experiences, etc. I was also anle yo have a hands in Peds rotation with an OR experience, Peds ER experience; in Maternity I was able to do PP, NICU, and worked side-by side with nurses and got to experience the birthing process 3 times, identify decelerations, variable decelerations, etc. We even have a neighborhood health clinic and a long standing NIH Asthma Teaching program. For my senior year, the hospital was awesome in making sure we had access to meds; we worked with the nurses side by side, and did a PACU and ER observation; I did telephone reports, etc during my rotations. It did help that the nursing instructors I had were either employed at that health system, or were great advocates to ensure that we had the ability to take advantage of a great clinical experience. I think this should be the rule, not the exception; I still think there should be a transition to practice model in place as well...to get those realities of being a licensed nurse in check, build those blocks on being comfortable in critical thinking and the nursing process...nothing's REAL to many until they are a licensed nurse, especially when a job is not within 3 months after the last clinical rotation in this market.

[PMFB-RN, RN]

Hospitals brought the problem of poorly-trained new grads on themselves.

*** Until a few years ago many hospitals were investing heavily in their new grads. The HAD to in order to reduce the sky high cost of constant recruiting and training due to high nurse turn over. It was cheaper to properly train new grads, thus increasing the chances they would stick around longer than to constantly turn over staff.

The solutuion that they have been working twords for a long time, and that they are now seeing bearing fruit, is the false "nursing shortage" propaganda. They have deliberatly created a oversupply of nurses. No there is no need to recruit. They can simply hire all the nurses they want and weed out the ones who don't adapt fast enough. Each of us now has a line of nurses just waiting for our job. It was deliberate. The economy just moved the over supply day ahead a few years.