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.
So, seeing both sides here, but am firmly in the camp of starting where you mean to end up.
However, I've seen new ER nurses that have done med surg, LTC, etc., and it's just like having a new grad. Sometimes worse, because they seem to think that I'm a young thing that needs to listen to them, not the COB-to-be that I really am. (Come to diety meetings and talks usually occur. I've been in this field way longer than they think, and I'm at least a decade older than they think I am. Reason to stay well-hydrated and to wear sunscreen!)
Simply put, they may want to be in the ED/ICU/critical care world, but that don't have the mindset nor the urgency required for some patients.
The first code is always interesting, since it can act as a test. Do they jump in, or do they panic?
A good orientation means the preceptor planning out the first few shifts as a chance to do some solid teaching, observing, and conferencing wroth the orientee. If possible, tale the lower - acuity patients. After that, work them up to having the 1:1 critical patients. Give them the OD that's sleeping it off along with the CP and the abd pain, then pull them into a STEMI to assist. Let them tale the boarder, then tips them the SBO. That sort of thing.
No real skills? I'll let them stick any healthy vein that is willing. AC first, then other places. (I have a list, and bring thank you treats.) NG tube? Here, this patient knows the drill, this one is sedated. My facility has a very, very short residency program, so it really is up to the department to teach all this.
And moat of all, be accessible even after they are of orientation. Remind them of their resources.
Sorry, rambled the for a bit. And I'm on the app on my phone, so blame auto-correct...
I have been thinking about this more and more. In the OP's case, have those things that the OP feels are lacking, have they been modeled by experienced RNs? Have the tasks been modeled and then had the new grad return demonstrate? I ask this because, starting off in a new position might make people hesitant about demonstrating a skill, sometimes wanting to see how it is done at that place of employment makes a world of difference. It would be interesting to see is to hear back again from the OP regarding what training model they are using.
For example with regards to log rolling, have the preceptors demonstrated and modeled the correct form, assisted the new grad with the techniques then observed?
As for the attitude... there probably should be a checkoff or something to call out the behavior in question.
Some people just always thing that they are the "it"
As a fairly new grad, I agree that nursing students are not taught what they need in nursing school, to survive in the real world. In my clinicals we were not allowed to push IV meds. We weren't allowed to give narcotics. In some hospitals we weren't allowed to take blood sugars. We weren't allowed to start IV's. We weren't allowed to pull meds.
In clinical we were glorified CNA's: Other than assessments, we took vitals, did AM care, answered call bells and gave meds to one patient if we were lucky. If we were looking up information about our patient to try to understand their condition and their plan of care (not that we had access to the computer systems), to ask ourselves what we would do as the nurse, we weren't "working". Why weren't we rounding and answering every bell? The patient in 256 is thirsty.
At one point during clinical I asked my instructor if I could just shadow/observe a willing nurse for a day...something, anything...to give me an idea of what it's like in the day of a nurse, how a nurse organizes his or her day, how a nurse thinks and manages time. Or if I could just forgo my bed baths for one day so I could observe what the nurses were doing. I was told, "You'll get that in orientation."
I was absolutely 100% willing to learn everything I could in clinical. I tried, but constantly hit road blocks. Nursing school clinical these days is excellent CNA training but hardly anything more.
While this may be true of your school and many others, I don't think it is right to lump all nursing schools together. The school I start in the fall allows IV's, med pushes, most all skills after passing competency exams. This is something I already knew about this school, and if I hadn't already known, it would have been one of my questions in my interview.
While this may be true of your school and many others, I don't think it is right to lump all nursing schools together. The school I start in the fall allows IV's, med pushes, most all skills after passing competency exams. This is something I already knew about this school, and if I hadn't already known, it would have been one of my questions in my interview.
Yes I know it varies state to state what students are permitted to do in clinical and I'm glad your school allows you to use a lot of the skills you learn in the clinical environment. We were "allowed" to use plenty of skills (Foleys, NG tubes, etc) but you'll see when you start nursing school how difficult it is to find opportunities. In the course of your clinical day, for example, there may be one patient who needs a Foley inserted. Half the time the nurse won't tell the clinical instructor and will just do it themselves to save time. The other half the time it will go to a student, but which one? There are six if you.
When you're a nurse you'll see, as I did, how it's hardly possible for nursing school to truly prepare you for nursing. There will never be a time in clinical where you're the sole caretaker of 5 acutely ill patients. I never started an IV or put an NG tube in a real person until RN orientation, but skills like that are easy to learn and anyone can learn them in a day. Learning these skills was a piece of cake compared to learning to shoulder the responsibility of the human lives under my care. That's where nursing school falls short. Hands on skills are such a small fraction of what a nurse is responsible for.
Specializes in Med/Surg crit care, coronary care, PACU,.
Without a valid mentorship program, nursing in specialties are only setting up new grads to fail. I am an emergency responder inside a hospital, and see this almost daily. Without experience, you cannot even advocate for your patients. Doctors do not like to be challenged, and in the ED even less. Those of us with experience are well known by all the physicians, and have a certain "street cred" that an honest interdisciplinary discussion can take place. New grads are often ignored by physicians. Not good patient care.
I agree 1000% with you. I work in psych and we get new nurses now that cannot get jobs in regular medical hospitals straight out of school. Most of them have the entitled attitude as well. People have the misguided belief that all you need to do in psych is talk to patients. Patients come in with medical issues , substance abuse and psychiatric diagnosis. It is not a walk in the park. It puts a extra strain on the nurse left to work with these nurses because management does not provide additional staff to work on the unit. They expect the new nurse to work in the same capacity of an experienced nurse. It is not fair to the experienced nurse, the new nurse or the patient.
We're discussing this exact issue in my PACU, largely because of me. Back in the day, PACU was largely staffed by former ICU and ED nurses, but that is no longer the case: I went into PACU straight from school after doing my immersion clinical there, and most of our recent hires have come from M/S, perhaps with some telemetry experience.
Some hospitals have rigorous orientation programs for specialty areas, usually because they actively recruit new grads. Our unit is not set up that way; we orient one-on-one with a preceptor, and the preceptor finds a good cross section of cases to help the orientee get familiar with how to recover different types of patients. I imagine our flow is a lot like the ED; you can't predict what's rolling in (well, we can look at the OR schedule), and you can wait a LONG time between patients needing particular interventions, such as hanging blood, dealing with chest tubes, managing an intubated patient, etc. If those things don't come up, you can't train on them.
The advantage my colleagues have in coming from M/S or any other background is that they came in knowing all the "nursing stuff" that I had to learn in the middle of a fast-turnover, unpredictable department. Thus they could focus on the critical care aspects of the PACU and not get hung up in the basics. But a good critical care orientation class would have helped me and probably the others as well.
So as a new grad who went into a specialty, I think it depends on how the orientation period is structured. And I do agree; some people are just a match and some aren't. The jury is still out in my case...
I totally agree with both of you. Worked 2years as a unit secretary during nursing school and 2years Med/Surg after graduation. MY units were were intense-vents,multiple serious conditions who needed to be in the ICU-no beds. Learned to hone my clinical,diagnostic skills there before going to Critical Care. I knew this helped me. For ex-worked on a step down CV surf unit-ONLY RN w/my hx: my coworkers freaked out,could not do colostomy care,insert Foleys, feeding/NG tubes,etc..I became the go to "girl" for these types of pts. No one else had my medsurg experience=priceless to me and my pts. Did not care that. Others looked down on it. IMO-smartest advice my professor ever told me.
Sorry so long-held this INSIDE to long. AGREE with original post/ comment regarding "elite" attitude with this very topic
I agree, they often need some med/surg experience first. There is just too much to teach and the ED is a very fast paced environment. Med/surg is it's own field, but it is a good place to see people in various levels of wellness/illness. While things can go bad quickly there as well, it generally isn't 2-3-4 patients going bad quickly at the same time.
Specializes in NICU( RN), Pediatric Nurse Practitioner.
I am doing a 16 week new grad residency program in the NICU. I think maybe hospitals should make all new grads do a residency program no matter what floor they get hired on.
Specializes in Family medicine, Cardiology, Spinal Cord Injury.
I'm all for nurses having a good foundation in med/surg, but what sucks is that you get those new grads on the medical unit that have that "entitled, elitist" attitude, who don't want to be there, but it's their foot in the door and access to their desired jobs. We train these nurses, only to lose them a couple years later to other departments.
I work in spinal cord at the VA hospital, and it's a tough unit to work on. A lot of our RNs do primary care on a consistent basis. This includes basic CNA work such as turning, bed baths, giving showers, transferring, and so on, as well as wound care, colostomy care, bowel care, bladder care, med admin, starting IVs and what not. Our new grad residency program is 1 year long, and after that, the new grads are on a one year probation in which we can evaluate them on whether they will survive working on our unit. We've had a lot of new grads and new hires quit the VA because the work was just too hard or below them. I mean, who wants to do digital stimulation on 4+ patients on a daily basis.
So yes train the new grads, be good about it, precept them, show them how it's done. But it's unfortunate that med surg is being used as a gateway or transition unit to better things.
Nonyvole, BSN, RN
420 Posts
So, seeing both sides here, but am firmly in the camp of starting where you mean to end up.
However, I've seen new ER nurses that have done med surg, LTC, etc., and it's just like having a new grad. Sometimes worse, because they seem to think that I'm a young thing that needs to listen to them, not the COB-to-be that I really am. (Come to diety meetings and talks usually occur. I've been in this field way longer than they think, and I'm at least a decade older than they think I am. Reason to stay well-hydrated and to wear sunscreen!)
Simply put, they may want to be in the ED/ICU/critical care world, but that don't have the mindset nor the urgency required for some patients.
The first code is always interesting, since it can act as a test. Do they jump in, or do they panic?
A good orientation means the preceptor planning out the first few shifts as a chance to do some solid teaching, observing, and conferencing wroth the orientee. If possible, tale the lower - acuity patients. After that, work them up to having the 1:1 critical patients. Give them the OD that's sleeping it off along with the CP and the abd pain, then pull them into a STEMI to assist. Let them tale the boarder, then tips them the SBO. That sort of thing.
No real skills? I'll let them stick any healthy vein that is willing. AC first, then other places. (I have a list, and bring thank you treats.) NG tube? Here, this patient knows the drill, this one is sedated. My facility has a very, very short residency program, so it really is up to the department to teach all this.
And moat of all, be accessible even after they are of orientation. Remind them of their resources.
Sorry, rambled the for a bit. And I'm on the app on my phone, so blame auto-correct...