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

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nursej22, MSN, RN

3,821 Posts

Specializes in Public Health, TB.

Lots of good advice here.

1) Management should know that a good orientation=well-trained, competent staff=better staff retention. Some bean-counter out to be able to figure out the return on investment here.

2) Yes, do a needs survey. You can do aSurveyMonkey for free, send it out to staff. Even if you only get a small return, at least you will get an idea where to start.

3) Use your manufacturer reps for equipment teaching and equipment fairs for things like specialized beds, lifts, drains, IV and central access devices.

4) Draft champions to do in-services at staff meetings even if for 10-15 minutes.

5) Love the idea of docs and mid-levels doing in-services, may once a month serve breakfast and offer CE hours.

6) Post to staff bulletin boards interesting, "did you know" articles around pertinent topics such as skin care, lab interpret, renal failure.

Good luck, unless the hospital is willing to invest in their staff, turn over ain't gonna get any better.

Specializes in OB.

I'm not an NP, but a CNM who lurks on this board from time to time. All I can say is yikes! A hospital that large should have an entire nursing education department, not one overworked educator. I agree with previous posters that if you jump into this mess, particularly for free, I'm sad to say you're helping them continue in this unsafe and toxic manner. My best advice would be to band together as many doctors and advanced practice providers (i.e., people who can bill for their services and therefore have leverage) as possible to demand a change in the nursing education department and be persistent about it. "Helping" in this manner isn't really helping in the long term, as much as I COMPLETELY understand your desire to help the nurses themselves.

Specializes in CVICU, MICU, Burn ICU.

It's great that you want to be helpful with this very overwhelming problem at your facility. You have had many great responses given to you here from various posters.

I will just say that this problem is way too big for you to fix. And you should NOT volunteer your time. The important thing to bring home to the powers-that-be in your facility is this: There are institutions that know how to retain and educate nurses. It is not rocket science but it will cost money. You absolutely cannot have the kind of orientation you are describing and have one educator for a teaching hospital that large (where you also have baby docs running around). There needs to be more experience retained. Your facility is eating the rotten fruit of its neglect.

Money talks. So get all the providers you can to demand better. As for your hands-on involvement, yes, by all means be that provider who takes the extra time with individual nurses to educate and train on whatever is coming up in the moment. As a group of providers come up with what inservices you wish the nursing staff could have because of deficits you have experienced. Encourage those nurses who want to hang around and/or have experience to get involved, form committees and work with your solo educator to come up with a reasonable approach to staff education --- which will, most definitely, have to involve hiring more educators.

Unless you are wanting to make a career change and go into education, I think you will make the most impact by actively being the concientious nurse you obviously are. Focus on impacting individuals. You will probably be very successful with that and I think the results will be farther reaching than overextending yourself in a doomed mission. It's up to the administration to fix the big picture problem, and they probably know exactly what they need to do to fix it.

RedForman

1 Post

Med surg units are commonly a dumpster fire for the floor staff due to management neglect. They usually only get turned around after a significant reckoning takes place, so there's truth to the notion that the place needs to metaphorically burn down before it can be fixed. The issues at play are probably so deep that you as an NP jumping in to solve them will likely do three things: 1) take yourself down a notch by distracting you from the job you went to school for, were hired for, and what should have your full attention (this goes for the other highly paid providers roped into this), 2) prevent or delay real and meaningful attention to the issues at play, and 3) depriving staff of focused RN focused leadership that is directly pertinent to their RN needs from their own perspective. You would be best utilized by going to bat for them to get the support that you can't provide. Every problem you look at will be seen through the eyes of what you think needs to be done.

Unfortunately, your two years of prior experience on that floor in your former role isn't enough to be able to form a solid foundation for you to be the expert for them to rely on, and obtaining our NP certifications dont really convey any further insight into the work they do. There simply isn't enough of you to spread among all the needs they have there. They need a professional nurse leader. You didn't do to school for that, and you don't have the experience as an RN or an educator to make up for that. But what you do learn in NP school among other skills is advocacy, leadership, generalized practice management, care coordination, and analytics.

The patients there are bringing in enough funding that the facility should be expected to provide a certain level of nursing care far above what it sounds like they are getting. Part of that expectation is that you and your provider colleagues are not also drawn in to participate in the present state of inadequacy to address problems that the hospital fostered. All of that is not fair to you, your colleagues, the staff, and the patients. They need nurse leadership and incentives in place to keep that brain trust around.

Don't be seduced into self sacrifice here, even a little bit. As nurses we sometimes feel like we should take on bad situations to fix them.... bad relationships, family issues, extra projects... things that really are against our own best interest. There's a reason you got your NP, and it not so you could go back and be a clinical nurse leader. A good point to emphasize in your advocacy is that it would be cheaper for them to hire an educator or a nurse leader than pay provider rates to you and your colleagues to get inadequate results. There is too much ground to cover if you are out on the floor doing entire orientations. It's not possible. Advocate. The money is there for the facility to do what they need to do. Don't enable them or volunteer your time, it will be wasted and unappreciated. This is an RN problem that needs to be solved through RN avenues.

Specializes in Geri - Edu - Infection Control - QAPI.
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.

You took (most of) the words right out of my mouth! I am a Staff Development Nurse at my facility and have seen crazy turnover. [Once oriented 6 nursing dept staff, only to have 1 remain after a month] I have been present during exit interviews and listened to nurses call out pay, patient ratios & patient acuity. I even heard a nurse say she'd rather go back to driving for Uber.

There is a fine line between doing something you're passionate about and doing it for free. If you say from the beginning you will do it for free, that will be expected of you and then may turn into an expectation of others. You cannot solve the problem in a few months, and I believe you're on the right track. Being present and visible to these nurses is huge. Eventually instead of you trying to figure out what to teach, they will come to you with questions. If you teach when the learner isn't ready to learn, you could be wasting both your time.

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.

A couple of mean, miserably unhappy nurses I worked with in ER wanted me to be in charge after just a couple of weeks. I stated that I didn't know what the duties of a Charge Nurse were. I felt forced to do it because I wanted to be liked and accepted and seen as competent.

Thank God nothing bad happened.

There is a fine line between doing something you're passionate about and doing it for free. If you say from the beginning you will do it for free, that will be expected of you and then may turn into an expectation of others.

I hope I did this quote right. In a business transaction that which is given for free has no value. At several points in my career nurses have tried to get me to "volunteer" my time for everything from coming in for uncompensated meetings to actually coming and cleaning up the unit. I tell them the same thing all the time "I play the pro game". I didn't go to nursing school then work on my DNP to do anything for free. Don't devalue yourself. Also, you have a valuable role to play as a provider. Concentrate on your patients and your job as a direct provider. Like a very good nurse I worked with once used to say all the time "stay in your lane". Focus on what you can change & not what you cannot. This dumpster fire is beyond your control.

Specializes in CEN, SCRN.

In my nursing school clinicals there was an NP who worked for CTS that rounded on the step down units. She had 30 minutes scheduled each day to do a brief informal brown bag with a unit of her choosing. Topics ranged typically on what she perceived needed to be covered. The couple times I sat in, she started off with "the other day I noticed there was confusion on..." or "I asked for a patient's last CBC and the nurse wasn't aware why the platelets were of importance to me, let's break down a CBC..."

Her talks were discussions and based on recent events but weren't threatening or accusatory. Just taking recent events and turning them into learning opportunities. All the nurses raved about her and her lunches and how they would fight each other to decide who had to watch the floor while she did her lesson. Since there were 3 floors she rounded on each floor got her 1-2 times a week.

That system will always stick in my head.

KatieMI, BSN, MSN, RN

1 Article; 2,675 Posts

Specializes in ICU, LTACH, Internal Medicine.

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, please help?

Thanks everyone!

For floor RN, ice very well may be the higher priority than that BP med. For multiple reasons, starting from that the patient, not you, will fill that HCAPS survey and to otherwise most wonderful idea of "the nursing means CARING for the PATIENT" (see the current topic named "No Respect" in General Nursing for great discussion about this).

I participated in one such project on one of my past jobs when I was a student NP. After the all interested persons sat down and looked through approximately random 1500 calls to providers from the unit, the following was done:

- re. procedural skills: 1) CLEAR (with pictures and video links posted on Intranet) instructions of what and how to do things (what to prepare and where to get it, then do 1, 2, 3...) easily available for staff RNs PLUS all Charge RNs were specifically taught the skills and made responsible for being immediately present in the room when the procedure was taken place PLUS absolutely, 110% agreement of not punishing RNs for asking the said Charges for help PLUS "toy kits" with instructions available in break room for everyone to handle and play.

- re. labs to call: every RN played a game of a "random lab of a week". Take a low potassium: what it is, how does it looks like (on tele, on exam), what causes it, what may happen, whatever you find interesting - write few words or make a picture on a card, drop it in the hat. Twice a week during shift huddle cards were read and one random author got a small prize. At the same time, clear and unequivocal instructions (name them policies, if you like) were written about what are norm and providers were educated about using replacement protocols when appropriate and WHY they may want to do so (they would get called less).

- likewise, every shift huddle a random RN was asked about one medication combination which would do... something (kill someone, cause Code Brown, cause Dr. "X" love you for life, etc) (dutifully administering meds which were forgotten to d/c was a big problem). Either correct (Levophed + metoprolol) or funny (Kayexalate and Ativan) combination brought something small and sweet. I named it Pharma Voleyball (and we threw a ball, too).

The whole shift huddle became way more lively, and nurses stopped grudging about them pretty soon, too.

- at the same time, several protocols were worked out. Nurses got new, more comprehensive, lytes replacement protocol, bowel regiment order set and a few others.

It took some concerted efforts and quite a job from several like-minded and very creative people, but in a few weeks nurses stoped being afraid of everything (and that was one of primary reasons for them to call providers for most trivial reasons) and started to think and analyze what they are doing. It was really a time (and little $$) well spent. After all, everybody remembered the "most crazy combination EVER" of Levophed and metoprolol in one single heart, and that was what mattered.

aprnKate

208 Posts

So i'm going to put my 2 cents here. I agree with everybody else that it is not really your job to train the nurses at your unit on how to manage flow. you nursing director or charge RN's job to get them precepted. When I was a new grad ER nurse back in 2008 the PA's and MD's in the ER were involved in making a clinical curriculum and taught not nursing stuff but the most common clinical presentations in the ER and what MD's/PA's/NP's expect RNs to do right away. I think this helped prioritize. The MDs/PA's presented power points and they took the time out of their own schedule to do this to ensure the RN's would be prepared as much as possible. Not only was this great but it also build rapport and MDs and RNs got a chance to know each other and build trust and be comfortable.

You're an NP. Not a nurse educator. Choose one or the other. You were trained to be a provider, so either do that, or go worry about issues back at the bedside.

Riburn3, BSN, MSN, APRN, NP

3 Articles; 554 Posts

Specializes in Internal Medicine.

The problems you mention sound more like a chronic top to bottom problem with your hospital in general. It sounds like their orientation and continuing education is lacking. By the time a nurse is off orientation they should already be "checked off" on performing some of the basic skills you mentioned as hold ups.

If the hospital isn't doing much about it, it's hard as a hospitalist to fix much, but there are some things you can do.

1) always round with your nurses. This way there is no miscommunication, and if they have questions you're available. Nothing bothers me more when a nurse ghosts you while rounding and then they call you 30 minutes later with a question that was addressed while you were rounding.

2) always go over the plan of care with nursing staff. Both long term and for that day. When I round I'm blunt and will tell them what I'm thinking and when the patient should be leaving.

3) if you see an opportunity to teach or demonstrate, Do it. Sounds like you have this down.

4) always stay in communication with your case managers. Where I work it's usually social, placement , or equipment issues that delay a discharge. I like talking with my case managers throughout the day.

Hospitalist programs in general help flow of the hospital when they take over since it's a 24/7 presence. The group I work for requires all discharge orders in by 11am if possible (and we are measured on this), and the hospital only gives nurses 2 hours to get the patients out (and they are measured on it).

As I said above though, it sounds more like a hospital administration problem and what you're already doing is pretty good, but you can only do so much.

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