We have several new grads in our ER. I'm starting to think that most nurses should have at least a year on a more general ward before learning a specialty.
I'm seeing some clueless mistakes, and lack of basic skill in pt care. That includes things like how to clean a pt and roll and change bedding. Basics about IV med administration, dose calculations, prioritizing, and realities of inpatient care. They have no idea how the rest of the hospital functions.
On top of that, some of them seem to harbor elitist attitudes, as if they are already big hotshots. Yet, they themselves seem to lack the above mentioned skills.
It has to start with the accrediting bodies for school, in my opinion. For instance, having 50% of your clinical hours in simulation is acceptable. To me going into our sim lab and waiting on people to get ready for the scenarios, then finally given a quick two-minute scenario is nothing but a waste of time to me. Doing catheters on mannequins that are not even close to the real thing is only good in lab when you are first learning the skills. Ours for the most part were broken, and you had to simulate putting the tube up in the member or urethra of the woman, whichever you got for check off. To most schools it's all about accreditation, which is mostly based on how many pass the NCLEX on the first try. The way nursing school is structured does not make much sense to me.
I was disappointed with my clinical experience last semester for several reasons. First, for medsurg II the RN cohort and LPN cohort were together. That's 40 people. In my town our choices for clinical sites are limited. We are not allowed to get any site out of our region. Which means none of the bigger city hospitals were not able to be used. Then, the LPN cohort went to the hospitals the first 8 weeks of the semester, while the RN cohort went the second eight weeks. We should have got the whole sixteen weeks. I disagreed with that aspect. The twenty of us in my cohort were divided into groups of ten. Ten went to one hospital, ten to the other. We each had one clinical instructor. She tried to divide us up into different areas for observation and we essentially got maybe 3 days on the floor. Three!! There were two teams on the floor. Each week a couple of those people on the floor were team leads. The team leads did not have a patient that day, they checked on their nurses. We could not do any procedure without our instructor present. She was usually with another student conducting med passes. We were supposed to be there for 12 hours but were usually there 7 or 8. We would work the floor in the morning, go to lunch, and do post conference. That was because we were told there wasn't much for us to do in the afternoon. I got to do some med passes and hang a couple of iv bags and push a couple of iv piggyback meds. My last day, I got offered by my nurse to start an iv and a catheter, but I couldn't without my instructor and she was ready for lunch. And in all fairness it would have held up the rest of my cohort waiting on me to do that. But I was frustrated that I couldn't do it. I loved my clinical instructor, and I think it was more of the way the program is set up than her fault. One clinical instructor can only do so much.
So much time is wasted over things that are not relevant. It's like this big roll of redtape that you have to get through to get clinical experience. I am choosing though to have some faith in my program as they have a great NCLEX pass rate and employers like to hire graduates of this program in my area any way.
But this fall is OB/peds. There are no pediatric units unless you go to the city and we cannot try to get a site there. But there is a big youth correctional facility. So, I don't know how that will work but I'm just going to plug through.
I get experienced nurse's frustration with new graduates, but we do not get anywhere near enough clinical time. It's all about passing that almighty NCLEX. And truth be told, it's not really the school's fault either. I feel it's the lax guidelines that the BON and ACEN have. There needs to be some kind of streamlining. We are also not allowed to chart anything but our vital signs and that we passed meds in my clinical. We are given a passcode and cannot access certain areas. I was told nurses are very particular about their charting. Which they should be. But for the person who had a student in the ER that didn't chart, she probably was not allowed per her school and hospital policy regarding students.
I'm just rolling with the punches right now. Our last semester is our capstone project which I think is us picking a specialty and having a preceptor. I am going to use all of that time to learn absolutely everything I can and practice skills so I hopefully will be somewhat familiar with the skill.
Specializes in NICU, PICU, PCVICU and peds oncology.
I think time management, organizational skills and prioritization are key ingredients in a well-prepared specialty nurse - whatever the specialty. I've worked with many new grads in the PICU over the years and can say that some have been phenomenal right off the bat, while others would never make the grade in a million years. Most, though, are in the middle. Good with some aspects of the work and not-so-good with others. And there's really no good way to pick out the stars from the rest. I agree that skills aren't the be-all-and-end-all and can be taught... as long as there's a foundation to build on. Blind placement of nasojejeunal feeding tubes is a good example. I've taught dozens of newer nurses how to do it, but they've all known how to place a nasogastric tube before we started. Calibration of pressure lines is another example. Without an understanding of atmospheric pressure and what causes changes in atmospheric pressure, all the new nurse is doing is what s/he was told in orientation classes. So when there's a sudden precipitous change in their patient's BP, they don't think to look out the window and perhaps recal their line. It's all about integrating the new with the known. Well-planned and executed orientations will meet that need. Whatever the specialty.
As Emergent stated, there does seem to be an over supply of ill equipped new grads with high self esteem.
Any feedback is met with defensiveness. When confronted about a major infraction of care, they are incapable of admitting responsibility for the error. Some are unteachable and really just a huge liability.
Certain individuals are ill equipped and too immature to start in a high acuity area and need a year in MS to learn basic nursing skills and have a major attitude adjustment.
It is unfair to them, and to us, to expect them to count as staff after twelve weeks.
We were just talking about this at work. Many of us believe that maybe, eventually, nursing may become a 5 year program like so many other degrees. This allows internships to take place and therefore more time to learn the basic essential skills. We are getting so many new grads who possess no basic clinical
skills such as IV's, placing ngs and catheters. It is starting from scratch for the first few weeks of orientation. Internships can allow more time on floors and working on actual patients to hone those skills. Even my one daughter, who is going to be a park ranger/wildlife biologist, will be in school for 5 years so that she can obtain hands on experience.
It is very possible for new grads to be successful in a specialty fresh out of nursing school. However, I do not think this is recommended for ALL new grads. I think the new grads that do fine are those who went to a good nursing school (adequate amount of clinicals, good clinical sites, ability to practice and learn skills), participated in a senior practicum in their specialty, worked as an aide preferable in the same hospital system, self-motivated and willing to study outside of work. I think med-surg is a specialty all on it's own, but is a great place to hone their time management, manage different disease processes and overall have less stress in a less acute area.
I have read most of the comments here. An observation I have made is that there are excellent points on both sides. I love reading these types of posts so I can keep them in mind when I am in clinicals and when I finally get my first job. I want to soak up as many tips as I can from you all.
Another observation I made: many are saying the fault lies with the instruction in school, and possibly with the lack of orientation at the first job. Both of these points I think sound totally valid. However, I am surprised there aren't any comments on the responsibility of the new nurses themselves.
I know that paramedic school is not the same. However, some things I don't think should be different... example: when we had student medics (and when I was a student medic), we didn't hold their hands and walk them through everything. We didn't even make them touch patients at all. If we/ they wanted to learn and get experience, we needed to step right in and get to work, not wait on the sidelines hoping someone would remember us and ask us to pretty please come start the IV on the patient. We were all responsible for our own education. If we felt like we lacked in something, we were expected to ask questions. If we didn't feel adequate in a task (like IVs or med pushes or reading EKGs...) we were encouraged to let instructors/ preceptors know so we could practice more. When I was having issues with IVs at first, I went into one of my first of many ED clinicals and approached my nurse preceptor and said: "Hey, I am not confident that I am doing well enough on IVs". Guess what? I got IVs all day long. By the end of that one clinical I was much better. When I was concerned about my ability to push meds, I got my text out and walked through the steps with props over and over until I could do it without ever having to really stop and think "now, what do I do next here?"
I will admit that I had several years of CNA experience, so rolling and things of that nature I am seasoned with. My point is just this: even if a nurse's program isn't stellar at instruction, isn't it still the student's ultimate responsibility to make sure they know their basic stuff? They do clinicals. Even if they can't do certain things, they can see what other nurses are doing, so shouldn't they know they are missing something? I'd go home and say "Hey Hubs! Lay here on this bed like you are unconscious. Don't help me at all. I'ma roll you around for a while... No.. not like that. Getcher head out of the gutter.."
Maybe I'm wrong... maybe I'm completely off base, but I really think it is the individual nursing student's responsibility to make sure she/he knows their stuff (in addition to the schools needing to make sure they train well, etc)
Whoa.. kinda wrote a book there. Sorry guys... I think I just wanted to write a lot so I could avoid going back to microbiology... final is thursday...
I am participating in a new graduate residency in the ER. It is modeled after the ENA's standards of orientation & customized by the hospital's most experienced ER nurses with supervision/input from the clinical nurse specialists & manager. Those same ER nurses work as preceptors for new nurses. My schedule is 40 hours per week: three 12 hour shifts & one 4 hour class focusing on case studies, skills practice & other "lecture" type content.
Not saying I am going to be an expert in the ER when it is over. But, I will be better prepared because my orientation is so intensive.
This comment needs a love button.
Every time I precept a student I always tell them that their certification test (be it the NCLEX or a NP certification) that they are studying for is a test to demonstrate minimal competence. Passing the certification tests mean very little- you have proven you know the bare minimum to start your career.
If you pass your test and think you are ready you are the most dangerous person because you do not know what you don't know. It is what you do after you pass your test that makes you a good nurse.
I have read most of the comments here. An observation I have made is that there are excellent points on both sides. I love reading these types of posts so I can keep them in mind when I am in clinicals and when I finally get my first job. I want to soak up as many tips as I can from you all.
Another observation I made: many are saying the fault lies with the instruction in school, and possibly with the lack of orientation at the first job. Both of these points I think sound totally valid. However, I am surprised there aren't any comments on the responsibility of the new nurses themselves.
I know that paramedic school is not the same. However, some things I don't think should be different... example: when we had student medics (and when I was a student medic), we didn't hold their hands and walk them through everything. We didn't even make them touch patients at all. If we/ they wanted to learn and get experience, we needed to step right in and get to work, not wait on the sidelines hoping someone would remember us and ask us to pretty please come start the IV on the patient. We were all responsible for our own education. If we felt like we lacked in something, we were expected to ask questions. If we didn't feel adequate in a task (like IVs or med pushes or reading EKGs...) we were encouraged to let instructors/ preceptors know so we could practice more. When I was having issues with IVs at first, I went into one of my first of many ED clinicals and approached my nurse preceptor and said: "Hey, I am not confident that I am doing well enough on IVs". Guess what? I got IVs all day long. By the end of that one clinical I was much better. When I was concerned about my ability to push meds, I got my text out and walked through the steps with props over and over until I could do it without ever having to really stop and think "now, what do I do next here?"
I will admit that I had several years of CNA experience, so rolling and things of that nature I am seasoned with. My point is just this: even if a nurse's program isn't stellar at instruction, isn't it still the student's ultimate responsibility to make sure they know their basic stuff? They do clinicals. Even if they can't do certain things, they can see what other nurses are doing, so shouldn't they know they are missing something? I'd go home and say "Hey Hubs! Lay here on this bed like you are unconscious. Don't help me at all. I'ma roll you around for a while... No.. not like that. Getcher head out of the gutter.."
Maybe I'm wrong... maybe I'm completely off base, but I really think it is the individual nursing student's responsibility to make sure she/he knows their stuff (in addition to the schools needing to make sure they train well, etc)
Great point! Totally agree!!! During clinicals I was grabbing the supplies out of my preceptors hand so that I could do the skill instead of just standing by and watching. My preceptor was somewhat of a control freak (nothing wrong with that) but I have to put my hands on something and DO it before I remember how...so grabbing the stuff and taking the initiative is how I made an impression during clinicals and I DID land a job in the ED out of nursing school because of it. :) Awesome post!
Maybe I'm wrong... maybe I'm completely off base, but I really think it is the individual nursing student's responsibility to make sure she/he knows their stuff (in addition to the schools needing to make sure they train well, etc)
I do agree that students need to take responsibility but I am finding the schools are often restrictive in what they allow. I graduated from an Accelerated BSN program and I was not allowed to start am IV on a patient in clinical. I was never allowed to take over total care of more than 2 patients. The school's restrictions prevented me from learning everything I should have. I came out of school needing more time management and IV skills-nothing I could have done would have changed this unless I wanted to risk getting kicked out of the program (though my role transition preceptor may have bent the rules a few times for me)
Why do they hire new grads in the ED??? It seems silly. A lot of people have not had a "clinically rich" school experience, esp in the specialties. We have lots of NG's in OB. Mostly, they are pretty good. Our ED has lots of new grads and it it obviously not a good idea. I guess no one else applies??? I would not work there!
I do agree that students need to take responsibility but I am finding the schools are often restrictive in what they allow. I graduated from an accelerated bsn program and I was not allowed to start am IV on a patient in clinical. I was never allowed to take over total care of more than 2 patients. The school's restrictions prevented me from learning everything I should have. I came out of school needing more time management and IV skills-nothing I could have done would have changed this unless I wanted to risk getting kicked out of the program (though my role transition preceptor may have bent the rules a few times for me)
Wow, it seems silly that a program wouldn't let you start IV's. But then again, I went to medic school when we were still allowed to practice IV's on each other (the students)... It really doesn't seem all that long ago, but when I tell people this today I get gasps. People are shocked. I can't imagine having to wait until I am OUT of school to LEARN a skill. That does make it tough.
NurseGirl525, ASN, RN
3,663 Posts
It has to start with the accrediting bodies for school, in my opinion. For instance, having 50% of your clinical hours in simulation is acceptable. To me going into our sim lab and waiting on people to get ready for the scenarios, then finally given a quick two-minute scenario is nothing but a waste of time to me. Doing catheters on mannequins that are not even close to the real thing is only good in lab when you are first learning the skills. Ours for the most part were broken, and you had to simulate putting the tube up in the member or urethra of the woman, whichever you got for check off. To most schools it's all about accreditation, which is mostly based on how many pass the NCLEX on the first try. The way nursing school is structured does not make much sense to me.
I was disappointed with my clinical experience last semester for several reasons. First, for medsurg II the RN cohort and LPN cohort were together. That's 40 people. In my town our choices for clinical sites are limited. We are not allowed to get any site out of our region. Which means none of the bigger city hospitals were not able to be used. Then, the LPN cohort went to the hospitals the first 8 weeks of the semester, while the RN cohort went the second eight weeks. We should have got the whole sixteen weeks. I disagreed with that aspect. The twenty of us in my cohort were divided into groups of ten. Ten went to one hospital, ten to the other. We each had one clinical instructor. She tried to divide us up into different areas for observation and we essentially got maybe 3 days on the floor. Three!! There were two teams on the floor. Each week a couple of those people on the floor were team leads. The team leads did not have a patient that day, they checked on their nurses. We could not do any procedure without our instructor present. She was usually with another student conducting med passes. We were supposed to be there for 12 hours but were usually there 7 or 8. We would work the floor in the morning, go to lunch, and do post conference. That was because we were told there wasn't much for us to do in the afternoon. I got to do some med passes and hang a couple of iv bags and push a couple of iv piggyback meds. My last day, I got offered by my nurse to start an iv and a catheter, but I couldn't without my instructor and she was ready for lunch. And in all fairness it would have held up the rest of my cohort waiting on me to do that. But I was frustrated that I couldn't do it. I loved my clinical instructor, and I think it was more of the way the program is set up than her fault. One clinical instructor can only do so much.
So much time is wasted over things that are not relevant. It's like this big roll of redtape that you have to get through to get clinical experience. I am choosing though to have some faith in my program as they have a great NCLEX pass rate and employers like to hire graduates of this program in my area any way.
But this fall is OB/peds. There are no pediatric units unless you go to the city and we cannot try to get a site there. But there is a big youth correctional facility. So, I don't know how that will work but I'm just going to plug through.
I get experienced nurse's frustration with new graduates, but we do not get anywhere near enough clinical time. It's all about passing that almighty NCLEX. And truth be told, it's not really the school's fault either. I feel it's the lax guidelines that the BON and ACEN have. There needs to be some kind of streamlining. We are also not allowed to chart anything but our vital signs and that we passed meds in my clinical. We are given a passcode and cannot access certain areas. I was told nurses are very particular about their charting. Which they should be. But for the person who had a student in the ER that didn't chart, she probably was not allowed per her school and hospital policy regarding students.
I'm just rolling with the punches right now. Our last semester is our capstone project which I think is us picking a specialty and having a preceptor. I am going to use all of that time to learn absolutely everything I can and practice skills so I hopefully will be somewhat familiar with the skill.