Prepare Nurses to Pass NCLEX, or Prepare Nurses for Real World?

JKL33 · Aug 13, 2020

I think you will be okay. You can do this.

In order to do it, go into the mode of getting done what needs to get done to succeed. Forget what other people do and forget perceptions of unfairness even if some things are unfair in some ways. Actually many things are. Not with regard to NCLEX, but I have been sort of where you are with dissatisfaction about some things in life, and please trust me the answer is to let it go and MOVE ON. Time spent wanting to avenge unfairness is time wasted and, more importantly, will blacken your soul. Decide if you want to be angry 2, 5, 10 years from now or if you want to look back and see all that you have conquered.

You only live once. Live as someone who knows when it is in your best interest to see things another way. This is one of those times.

Do those NCLEX practice questions and say to yourself, "Ah, I see what is being said here with this rationale." Incorporate the principle that is being emphasized. If you have questions about a rationale, by all means come here and people will help you.

Forget what you know (by this I mean the way that you have applied previous knowledge of another discipline within that other discipline).

Think nursing. And as you progress from being a novice to an expert nurse, you will have plenty of opportunity to integrate the strengths of your previous knowledge into your nursing practice. Isn't that great? Feel positive.

Know that it is okay to be back at baseline, back at square one, back at being a novice. You have not experienced that for awhile, and it is a very uncomfortable feeling; it's not a fun position to be in. But anyone who wants to succeed at something new must go through it.

Okay? How does this sound?

???

HiddencatBSN, BSN · Aug 14, 2020

9 hours ago, macawake said:
A lactation consult, stat!
(Sorry, I know it’s just a typo. Just thought this angry thread could use a little levity ?)

I’m leaving the typo for the lols ?

londonflo · Aug 14, 2020

On 8/13/2020 at 9:13 AM, Nurse Beth said:
I've thought for a long time that we need to go to a medical model, where nurses are given progressive independence. A year of residency, with a fellowship after that for specialties.

On 8/13/2020 at 12:15 PM, emtpbruse said:
Second, I appreciate "Nurse Beth" who made the recommendation for "Progressive Independence" along with extended precepting periods of 1-yr. for new nurses. Some of the hospitals in my area have already implemented this form of training upon being hired and maybe it's the NCLEX replacement we need to consider moving into the 21st Century.

Nurse Beth:

Were you suggesting "institutional licensure"?

Quote
Institutional licensure: allows the institution (hospital, nursing home, etc.) to decide what qualifications are necessary and who can work as a nurse.

This comes up periodically but usually by hospitals or nursing homes.

9kidsmomRN · Aug 20, 2020

On 8/9/2020 at 12:00 PM, emtpbruse said:
On August 7, 2020 I took the NCLEX for the second time and FAILED. I paid $70.00 to the NCSBN for a 5-wk study course, including test questions. I used UWorld and other resources such as Sanders and NCLEX cram study guides. NOTHING...NOTHING I reviewed assisted me with the NCLEX exam several days ago and I believe I did worse the second time than I did the first time

Sometimes having more knowledge/ experience actually hurts you in testing. The NCLEX is looking for you to answer according to the textbook not based on what you would/can do in the real world. For the annual EKG test at my hospital, I tell the ICU nurses to answer according to ACLS guidelines not according to what they would do with the PRNs that they usually have available. I’m sorry for your difficult time with the NCLEX. I wish you good luck with your next test!

9kidsmomRN · Aug 20, 2020

On 8/12/2020 at 4:25 PM, Susie2310 said:
In most areas of the country, even Associate Degree prepared nurses are expected to be the Charge Nurse sometimes and to have a basic knowledge of being a team leader, make staffing decisions, participate in policy development, etc

Yes, I did all of that as an ADN back in the 90s. I still don’t see any difference in roles at the bedside between BSN and ADN nurses. At my hospital they require BSN for managers and educators, but involvement on Professional Governance and other committees is encouraged for all nurses. Charge Nurses, Clinical Leaders/Shift Leaders can be either.

NCLEX Columnist · Aug 20, 2020

I agree. The model in which students are being taught is inadequate at best. Students are receiving less hands-on clinical experience (this was a problem way before the pandemic), and students aren't being provided ongoing opprotunities to develop critical thinking skills, or have their questions answered or clarified.

Majority of the students that I have taught over the years (lecture, skills lab, clinical, staff development, tutoring, etc.) come to me with a common complaint - When they ask for further explanation or guidance on a particular topic or concept - they are told to "read the book", or "Look it up".

The first time I heard those same words uttered to me when I was asking for clarification because I was afraid of making a medication error during my fundamentals clinical rotation, I respectfully replied "I will not continue with the medication pass until I receive the clarification I need because I do not want to risk the safety of this patient." When the instructor asked "Are you refusing to follow directions?" I replied "No, I am asking that you validate my understanding so I feel more confident in what I am doing so that I do not make a mistake." My instructor then smiled, and replied "Good job. Advocating for the safety of your patient is always priority #1.", and then she provided me with the clarification I was requesting. Turns out I was correct all along, and with her validation of my understanding, I confidently continued to administer the patient's medications safely.

Although I appreciated the lesson that my instructor provided for me on that day, I also recognized how that could potentially create a negative learning environment for many, and from that day forward, I vowed that I would never respond to a student, new hire, or client the same way.

Teaching is not easy. Nursing is not easy. Being a great nurse is certainly not easy. Why would a nurse educator ever feel like they are being helpful when they say things like "look it up", or "read the book"?

A nurse would NEVER ask a patient "Did you read the pamphlet I gave you?" in response to a question - so why do we treat our students so differently? This needs to stop.

This is one of the major barriers for student success and the development of critical thinking skills in our nursing students. If they are intimidated and afraid of asking questions because they continually receive snarky, aggressive or demeaning responses - they will NEVER seek clarification, and they will lay low, focus on content only, and barely make it through school undereducated, and unprepared to enter into the profession.

The status quo has got to go!

Let's get to work!

-Damion

londonflo · Aug 20, 2020

3 hours ago, Damion Jenkins said:
When they ask for further explanation or guidance on a particular topic or concept - they are told to "read the book", or "Look it up".

I can state that I never used the "read the book" retort, but I do recall students coming to me with not having prepared ( via scheduled and open lab, video links provided as a required activity and time necessary to do the learning activities provided) to perform the intervention they were scheduled to do and didn't have any idea of what materials were needed and how to safely perform the skill. That is a situation where, asking the student to describe their preparation and what is necessary to do in preparation needs to be reflected back to them to prevent an reoccurance in clinical. As you noted clinical time may be limited and passing on skill performance because of poor or no preparation does the student no good for learning. Should the instructor "talk the student through the skill?" The answer to that question really depends on the situation. Does the patient feel assured of a student's ability if it appears they need very specific directions to complete a simple skill? Will the patient decide they do not feel having a student nurse assigned to their care is in their best interests? Does having a unprepared student cause a painful procedure to be prolonged due to the necessity of instructions? All these things need to be considered and I can tell you this can be a tough situation to handle.

3 hours ago, Damion Jenkins said:
, I respectfully replied "I will not continue with the medication pass until I receive the clarification I because I do not want to risk the safety of this patient."

I love your example. It sounds like the information you needed for safe practice was not available to you by anyone other than your instructor. Great job for illustrating this. There is a time and place for when questions can be asked. Of course, I have run into this situation often and appreciate your example. However, sometimes a student will come to the medication administration requesting information that was part of their preparation. For example, when giving a scheduled insulin dose with a correctional dose also due. The student draws up the scheduled and then turns to the instructor and says what was their BS? The student has not searched out this information despite the necessity of knowing it was going to be needed since the start of their clinical day. I used to teach evenings and 9 PM can be as hectic as 9 AM in medication delivery with students. Every student who comes to the situation unprepared can make every student late in their medication administration and actually disrupt a patient's bedtime routine. So there are times I provide the information to facilitate getting everything done, to provide each student with adequate time but not allow one student to monopolize the instructor's time. Being an instructor requires a lot of preparation too. Choosing assignments that helps each student progress in their skill and knowledge development and providing a skilled performance for the patient.

3 hours ago, Damion Jenkins said:
they will NEVER seek clarification, and they will lay low, focus on content only, and barely make it through school undereducated, and unprepared to enter into the profession.

I agree. I see this frequently on the clinical units I regularly go to. I am approachable and have had nurses listen when I explain something to a student or come and ask me something privately. I appreciate they trust me to confidentially explain something that was basic nursing school knowledge.

Can I just mention something that drives me crazy? When a student is preparing their first injections (a right of passage we all went through) even though they have handled the equipment in lab several times, they are often very slow and unsure. It is tough to "keep my hands in my pockets" but I often look away or talk quietly to someone while watching out of the corner of my eye. A staff nurse watching the student sometimes takes the equipment and says "here let me show you". That just defeated the whole preparation experience of having the student do it. I often wonder if the staff nurse thinks I am mean for not doing that myself! If a staff nurse has a consistent habit of doing this sometimes I have to talk to them alone and explain. It is always best to prepare meds with students away from the common prep area to avoid this!

As you can see a always write a book!

NCLEX Columnist · Aug 23, 2020

On 8/20/2020 at 2:17 PM, londonflo said:
Should the instructor "talk the student through the skill?" The answer to that question really depends on the situation. Does the patient feel assured of a student's ability if it appears they need very specific directions to complete a simple skill? Will the patient decide they do not feel having a student nurse assigned to their care is in their best interests? Does having a unprepared student cause a painful procedure to be prolonged due to the necessity of instructions? All these things need to be considered and I can tell you this can be a tough situation to handle.

Thank you londonflo for your contribution to this discussion thread.

I agree that it does depend on the circumstance and situation whether or not I would talk a student through a skill. What I have learned over the years of teaching clinical is that I have the students articulate to me what they should do before they even go into the room. If they cannot, then we have further discussion that leads them to the resources they need to gather what they need to inform themselves. If the student freezes, or asks questions that may make the patient uncomfortable, I typically intervene to break the tension, have a discussion with the patient and student surrounding performance anxiety, learning, student stress, etc. and I assess the situation. If I feel the student is unprepared, then I have them practice at home or in the school lab, and then they can attempt on the next clinical day. If they are able to muster up the focus and get through their nerves and the patient is onboard with it, we move forward. It really does depend on the situation.

On 8/20/2020 at 2:17 PM, londonflo said:
However, sometimes a student will come to the medication administration requesting information that was part of their preparation. For example, when giving a scheduled insulin dose with a correctional dose also due. The student draws up the scheduled and then turns to the instructor and says what was their BS? The student has not searched out this information despite the necessity of knowing it was going to be needed since the start of their clinical day. I used to teach evenings and 9 PM can be as hectic as 9 AM in medication delivery with students. Every student who comes to the situation unprepared can make every student late in their medication administration and actually disrupt a patient's bedtime routine. So there are times I provide the information to facilitate getting everything done, to provide each student with adequate time but not allow one student to monopolize the instructor's time. Being an instructor requires a lot of preparation too. Choosing assignments that helps each student progress in their skill and knowledge development and providing a skilled performance for the patient.

I agree 100%. If a student asked me what the patient's blood sugar is when they were supposed to give insulin, I would most definitely say - "You need to know that before you can give them insulin." That would be expected for any student. I am well versed in the intricacies of working and teaching all shifts, and in a variety of settings - so I get it. Choosing assignments takes a lot of careful consideration, however I found what makes it easier overall is having a set schedule for all the students to focus on certain assignments so it helped me even up the playing field. For instance - On day one, all of the students have the same assignment/tasks:

Orientation- computer training, tour of facility, scavenger hunt on unit, interview two patients.
Day two- 3 students were completing assessments and providing all ADL care for 2 patients, and 3 students were focusing on their care plan assignment.
Day three- 3 students were completing assessments and providing all ADL care for 2 patient, and 3 students were focusing on their care plan assignment (switched from day two).
Day four - 3 students give AM meds and complete assessments and ADL care for 2 patients, 3 students complete their safety assignment.
Day five - 3 students give AM meds and complete assessments and ADL care fore 2 patients, 3 students complete their safety assignment (switched from day four).
etc....

I found this method MUCH easier - and the students really liked knowing what they had to focus on each day from the very first day. If you're ever interested in a template - let me know!

On 8/20/2020 at 2:17 PM, londonflo said:
Can I just mention something that drives me crazy? When a student is preparing their first injections (a right of passage we all went through) even though they have handled the equipment in lab several times, they are often very slow and unsure. It is tough to "keep my hands in my pockets" but I often look away or talk quietly to someone while watching out of the corner of my eye. A staff nurse watching the student sometimes takes the equipment and says "here let me show you". That just defeated the whole preparation experience of having the student do it. I often wonder if the staff nurse thinks I am mean for not doing that myself! If a staff nurse has a consistent habit of doing this sometimes I have to talk to them alone and explain. It is always best to prepare meds with students away from the common prep area to avoid this!

This is also a right of passage for nursing instructors - staff nurses always mess up our plans! Haha.

What I've learned to do is to go around and introduce myself to every single staff member (Nurses, UAPs, Clerks, Janitors, Managers, etc.) and let them know who I am, who my students are, where my students are assigned, and what the expectations of the day are. Each nurse gets details regarding what skills, assessments, documentation, ADLs, etc. will be done for the patients. I also ask kindly for the nursing staff to allow the students to work through the motions independently, unless there is a safety concern and they need to intervene. I also ask kindly that they report ANY issues, behavior, or student concerns to me immediately. If the unit has communication devices that the staff use, I ask if I could use one while on the unit. If they do not, or will not give me one, I will give them my cellphone number. This has helps greatly with preventing these types of incidents from happening.

I appreciate your insights, and if someone hasn't told you lately - THANK YOU for your contributions to the nursing profession and for serving others! You are appreciated and valued!

Best,

Damion

londonflo · Aug 23, 2020

4 hours ago, Damion Jenkins said:
And what makes it easier overall is having a set schedule for all the students to focus on certain assignments so it helped me even up the playing field. For instance - On day one, all of the students have the same assignment/tasks:
Orientation- computer training, tour of facility, scavenger hunt on unit, interview two patients.
Day two- 3 students were completing assessments and providing all ADL care for 2 patients, and 3 students were focusing on their care plan assignment.
Day three- 3 students were completing assessments and providing all ADL care for 2 patient, and 3 students were focusing on their care plan assignment (switched from day two).
Day four - 3 students give AM meds and complete assessments and ADL care for 2 patients, 3 students complete their safety assignment.
Day five - 3 students give AM meds and complete assessments and ADL care fore 2 patients, 3 students complete their safety assignment (switched from day four).
etc....
I found this method MUCH easier - and the students really liked knowing what they had to focus on each day from the very first day. If you're ever interested in a template - let me know!

An interesting plan for clinical learning experiences for sure. I have always had a clinical "focus" for each day - one that is related to the theory content that week. Each student receives all their focus sheets at orientation with the clinical calendar. So they knew in advance what the foci was and knew to bring their resources like a care plan book, (drug guide always) his also details what written work is assigned and the due date (next clinical day) lab and clinical diagnostic book etc. Since our students are so often working, have families etc. I have found it is best to explain what week(s) have the bulk of the written work (process recordings, care plans) for them to work around.

About 5 years ago, we were forced to go to 12 hours clinicals per hospital requests. I still have a hard time accepting this as I always like the 2 shorter days for at least beginning students. One of the best things about having a patient for two days is students get to repeat many of the "challenges" of the day before and feel more organized, more knowledgeable about the patient and can improve on skills. Repetition has a place in education. It also helps the students build confidence. (the degree that students repeat the same skills always generates discussion among faculty members. Faculty and graduate nurses opinions vary!)

Clinical time is so valuable that students did do assessments, ADLs, any other skills like dressing changes and medications every clinical day. Frankly it is a communication nightmare if a staff nurse has one student who gives meds and one who does not. It is really hard on the CNA if only some students do ADLs, some not. Thoroughly depending on the posted info with the assignment sheet (and even verbal followup) just didn't cut it for me. Staff are just too busy, things would get missed - if they have more than one student and that happens in specialty areas with limited beds and even with whole floors (like medical, surgical).

4 hours ago, Damion Jenkins said:
What I've learned to do is to go around and introduce myself to every single staff member (Nurses, UAPs, Clerks, Janitors, Managers, etc.) and let them know who I am, who my students are, where my students are assigned, and what the expectations of the day are. Each nurse gets details regarding what skills, assessments, documentation, ADLs, etc. will be done for the patients. I also ask kindly for the nursing staff to allow the students to work through the motions independently, unless there is a safety concern and they need to intervene.

I was in a unique situation in that I had educated many of the staff nurses I worked with. I had been on the oncology floor longer than any staff nurse including the manager! Staff did receive the information you outlined and the student assignment sheet always stated med administration and which ones. Students had their first and subsequent experiences with oral, sub q and IM (rarely) after the lab content. I had 10 students so meds really kept me busy. We gave meds every clinical day since there were only 16 clinical days per semester. I taught the pharmacology course so I could also schedule the content in class to dove-tail the clinical assignments. What really slowed us down with med adminstration was Meditech .Students had computer orientation but it was hard to master it efficiently. Meditech has so many different prompts with charting. I envied the faculty who taught students in their second year who had become familiar with computer charting. I spent a lot of time answering questions about it.

4 hours ago, Damion Jenkins said:
If the unit has communication devices that the staff use, I ask if I could use one while on the unit. If they do not, or will not give me one, I will give them my cellphone number. This has helps greatly with preventing these types of incidents from happening.

I found also a quick catch up with the staff after clinical was important to hear their concerns, compliments about the student(s) who were assigned to their patients.

I enjoyed reading how your clinical days were scheduled. At the colleges I taught at, faculty really tried to have our clinical days run a similar way - still we got the familiar questions "what do you want?" during orientation as I am sure you have been asked.

HiddencatBSN, BSN · Aug 23, 2020

5 hours ago, londonflo said:
An interesting plan for clinical learning experiences for sure. I have always had a clinical "focus" for each day - one that is related to the theory content that week. Each student receives all their focus sheets at orientation with the clinical calendar. So they knew in advance what the foci was and knew to bring their resources like a care plan book, (drug guide always) his also details what written work is assigned and the due date (next clinical day) lab and clinical diagnostic book etc. Since our students are so often working, have families etc. I have found it is best to explain what week(s) have the bulk of the written work (process recordings, care plans) for them to work around.
About 5 years ago, we were forced to go to 12 hours clinicals per hospital requests. I still have a hard time accepting this as I always like the 2 shorter days for at least beginning students. One of the best things about having a patient for two days is students get to repeat many of the "challenges" of the day before and feel more organized, more knowledgeable about the patient and can improve on skills. Repetition has a place in education. It also helps the students build confidence. (the degree that students repeat the same skills always generates discussion among faculty members. Faculty and graduate nurses opinions vary!)
Clinical time is so valuable that students did do assessments, ADLs, any other skills like dressing changes and medications every clinical day. Frankly it is a communication nightmare if a staff nurse has one student who gives meds and one who does not. It is really hard on the CNA if only some students do ADLs, some not. Thoroughly depending on the posted info with the assignment sheet (and even verbal followup) just didn't cut it for me. Staff are just too busy, things would get missed - if they have more than one student and that happens in specialty areas with limited beds and even with whole floors (like medical, surgical).
I was in a unique situation in that I had educated many of the staff nurses I worked with. I had been on the oncology floor longer than any staff nurse including the manager! Staff did receive the information you outlined and the student assignment sheet always stated med administration and which ones. Students had their first and subsequent experiences with oral, sub q and IM (rarely) after the lab content. I had 10 students so meds really kept me busy. We gave meds every clinical day since there were only 16 clinical days per semester. I taught the pharmacology course so I could also schedule the content in class to dove-tail the clinical assignments. What really slowed us down with med adminstration was Meditech .Students had computer orientation but it was hard to master it efficiently. Meditech has so many different prompts with charting. I envied the faculty who taught students in their second year who had become familiar with computer charting. I spent a lot of time answering questions about it.
I found also a quick catch up with the staff after clinical was important to hear their concerns, compliments about the student(s) who were assigned to their patients.
I enjoyed reading how your clinical days were scheduled. At the colleges I taught at, faculty really tried to have our clinical days run a similar way - still we got the familiar questions "what do you want?" during orientation as I am sure you have been asked.

My students were with me for 3 clinical days before they went to another clinical since I was in a specialty area, and due to the unit I was on, we couldn’t plot out assignments in advance. The students didn’t get computer training due to how briefly they were on site so were limited in what they were able to do since they couldn’t document. My first day was a brief orientation to the specialty, the unit, and then I went with each of them to assess and do vitals on a patient, and by the time we had that done there was usually a fresh batch of patients to assess so I’d send them in independently for the next round. My goal over the 3 days was to get everyone the opportunity to assess a patient in each developmental age range. My group of seniors saw more patients than they had in their previous peds rotation because their peds clinical had often taken adult patients due to low census and my juniors had no peds experience at all so I focused on getting them broad exposure to tailoring approach to developmental age. It was such a short time to accomplish that and the unit offered a lot of opportunity to see interesting things but required a lot of in the moment flexibility.

londonflo · Aug 23, 2020

45 minutes ago, HiddencatBSN said:
My first day was a brief orientation to the specialty, the unit, and then I went with each of them to assess and do vitals on a patient, and by the time we had that done there was usually a fresh batch of patients to assess so I’d send them in independently for the next round. My goal over the 3 days was to get everyone the opportunity to assess a patient in each developmental age range.

It sounds like a wonderful experience due to your planning on an unplannable clinical site. It is so beneficial to perform a high level skill such as assessment with an expert present and then perform one independent but still having access to the expert. And then to add growth and development which is really hard to incorporate when peds census is low (except in respiratory season!). Our campus has a child care center and I asked if we could consider nursing students doing physical and developmental assessments. One instructor said we would need to have the signed permission of the parent(s). I was not proposing anything invasive but since this is not my area I accepted her objection. More than 45 years ago, I learned the norms of children when we shared a clinic experience with the university dental students. It was a great experience (I can still recall it) A side benefit was I learned to recognize gross caries and used that skill when I worked at the Boys Club.

You mention both juniors and seniors. Do you have both level students in a clinical group? Thanks for telling your experience. With creativity and ingenuity including persistence we can meet the course goals in non historically standard settings.

HiddencatBSN, BSN · Aug 23, 2020

15 minutes ago, londonflo said:
It sounds like a wonderful experience due to your planning on an unplannable clinical site. It is so beneficial to perform a high level skill such as assessment with an expert present and then perform one independent but still having access to the expert. And then to add growth and development which is really hard to incorporate when peds census is low (except in respiratory season!). Our campus has a child care center and I asked if we could consider nursing students doing physical and developmental assessments. One instructor said we would need to have the signed permission of the parent(s). I was not proposing anything invasive but since this is not my area I accepted her objection. More than 45 years ago, I learned the norms of children when we shared a clinic experience with the university dental students. It was a great experience (I can still recall it) A side benefit was I learned to recognize gross caries and used that skill when I worked at the Boys Club.
You mention both juniors and seniors. Do you have both level students in a clinical group? Thanks for telling your experience. With creativity and ingenuity including persistence we can meet the course goals in non historically standard settings.

I taught 2 semesters (well, 1.5 because of covid) so my first semester was seniors and the second was juniors. We were in the children’s er where I taught and let me tell you a 7-2 clinical is not ideal for peds er time except during respiratory season- in the early fall we’d come in to a census of 0 or only peds psych boarders who were not always good candidates to have students (although my students did get to see some of them, and we were paired with their psych rotation so that was a good tie-in). Census would start picking up around 10/11 am. Most of them had peds clinical scheduled in the city their school was in (my location was a 60ish minute drive from campus) and the peds unit there was small and most stuff ended up being sent to us so aside from being a small unit the local clinical was more limited. They’d never done a peds ED clinical at the school but I got really positive feedback from the students on their experience.

I had to draw a ton from my memories of clinical 10 years ago, and what I remembered from my peds clinical was how my instructor really focused on exposure and comfort with peds patients, and it really is a very different approach to even do simple assessments and vitals on an infant or toddler than an adult. I did preconferences on techniques for different developmental stages, the Pediatric Assessment Triangle, and triage and acuity since we were in the ED. Their care plans/maps were very inpatient-centric and often included sections we either didn’t have data on yet (labs resulted, admitting diagnosis, etc) so I had them focus on the developmental stages and anticipatory guidance and teaching for the chief complaint.

I wish we could have had a later clinical, or more sessions together, and if I do this again I think I’d prefer being on an inpatient unit where I could have some predictability/plannability for patients. I kept a chart of what age ranges each student had had and which section of the department they’d had patients in (and after my first group which nurse had their patient after I identified which staff nurses were better with students), and as patients came in to the ED I’d assign them based on that. And if anything sparked their interests we’d shift the assignment to allow them to follow that as a small group of 2-3 students.