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

londonflo · Aug 3, 2020

1 hour ago, Hoosier_RN said:
My comment stands. The schools teach to the NCLEX, and some of these graduates barely know the basics of nursing care.

I didn't realize you were talking about the delivery of the basics. I stand corrected and I hope I have it right this time. I was struggling with the facts that NCLEX focuses on patient safety among other concepts. A faculty member did a study correlating our students grades in the nursing foundation courses with the passing of NCLEX. The grades received in the first and second nursing courses correlated highly with passing NCLEX. It is that important. But I agree with you that students/staff do not employ the basics as much as they should. I see this on the floors and as a patient. No prompting to ambulate and shower, change gown, perform DB and C.. that kind of thing. You will find this bizarre but my first nursing job was on a post-op floor. One of the orders was to perform PROM bid on patients. These patients had cataract surgery, appys, turps etc and were more than capable of AROM. Yet I still did it!

**CommunityRNBSN, BSN, RN** · Aug 3, 2020

I attended an accelerated one-year program. Obviously we spent time before starting getting our prerequisites, which were the Microbiology, genetics, Chemistry, etc. But the thing I remember clearly is that early on, our professor said “When you graduate from here, will you be prepared to walk in and take an assignment of four or five med-surge patients? NO. We are only teaching you the basics. You will need a lot of teaching once you get a job; that is why many hospitals have residency programs.” Which makes sense of course— it’s a one year program, there’s a practical limit to what they could teach us in that amount of time. But it was sort of striking to realize that this is the system that is being envisioned these days: Nursing school is for some overarching basic concepts, and for a license, but not really to prepare you for practice.

And it does create gaps. For example, many of us do not enter residencies! I went straight into FQHC work. I like to study and I’m a self-motivated person, so I actually feel like I’ve become pretty competent in my niche. But it still doesn’t seem like a great system.

Susie2310 · Aug 3, 2020

22 hours ago, londonflo said:
In order to enhance a students ability to provide expert teaching, the student must have direct experiences with public health nurses, home health nursing practice, clinic and office nurses, and other positions OUTSIDE the hospital.Otherwise how can we refer patients appropriately, explain to patients what the home healthcare nurse will provide, and so they understand when to call the physician's office. While we treasure our roots and the expertise of bedside nursing, the expert skills needed in direct patient care, we cannot limit the focus of nursing to a bedside role.

While nurses work in other areas besides the hospital (although the majority of nurses work in hospitals), traditional bedside med-surg nursing education and training is fundamental to all of the areas nurses work. It is basic training. It was fundamental in Florence Nightingale's day, and is fundamental now. Without these basics, nurses never acquire a proper foundation for their practice. This is what we are seeing today and have been seeing for over 20 years. This process has only increased. The fact that more nursing takes place in the community now does not negate the need for these basics. Patients still have the same medical problems and the same nursing needs. Only now, many nurses are not capable of providing nursing care.

The foundational training provided in traditional bedside med-surg education/training is the basis for all the other areas where nursing is practiced, I.e clinics, offices, public health, and other outpatient settings. My ability to practice in these other areas would have been much more superficial without first acquiring a foundation in bedside med-surg nursing. And that is what we see today, and have seen for some time; a very superficial practice of nursing.

The nursing schools have relationships with businesses that employ nurses. The businesses are looking for the nursing licensure, and then they will mold the employee to the employer's demands. Being the right kind of employee is far more important. As far as I know, the generic BSN students' lack of clinical education/training didn't hamper their ability to find jobs. Business relationships is the key, not actual student preparation/ability.

I often notice a huge dichotomy between the job requirements for nursing positions I see advertised, and the calibre of the nurses I see working. I have come to believe, based on what I have seen/experienced, that knowledgeable, ethical, competent bedside practitioners; nurses who employ critical thinking and use the Nursing Process as the backbone of the care they provide, are not generally desired as employees. What I see preferred is a much dumbed down model; practicing nursing as merely a series of tasks and obedience to employer directives with minimal critical thinking.

To my knowledge, the nursing schools are responsible for these changes in nursing education, as I remember what I witnessed in my BSN Bridge program years ago. I remember the talk, then, of how nursing was moving out into the community, and how more nursing would be provided in the community in future, and of course, how nursing was moving towards the BSN. The huge push by nursing academia to elevate the nursing profession was taking place; the desire to increase the supply of Nurse Practitioners, and to raise the entry level to practice. None of this happened by accident.

We read here of nursing students in BSN programs complaining that their BSN program didn't teach them how to be a bedside nurse; that virtually the whole emphasis was on preparing them for NP school, and that they felt they had been cheated out of their education as they had gone to nursing school in order to learn the basics of being a nurse I.e. how to provide basic nursing care.

The consequence of all this is that patients suffer as nurses don't know how to provide nursing care.

Hoosier_RN, MSN · Aug 3, 2020

12 minutes ago, Susie2310 said:
While nurses work in other areas besides the hospital (although the majority of nurses work in hospitals), traditional bedside med-surg nursing education and training is fundamental to all of the areas nurses work. It is basic training. It was fundamental in Florence Nightingale's day, and is fundamental now. Without these basics, nurses never acquire a proper foundation for their practice. This is what we are seeing today and have been seeing for over 20 years. This process has only increased. The fact that more nursing takes place in the community now does not negate the need for these basics. Patients still have the same medical problems and the same nursing needs. Only now many nurses are not capable of providing nursing care.
The foundational training provided in traditional bedside med-surg education/training is the basis for all the other areas where nursing is practiced, I.e clinics, offices, public health, and other outpatient settings. My ability to practice in these other areas would have been much more superficial without first acquiring a foundation in bedside med-surg nursing. And that is what we see today, and have seen for some time; a very superficial practice of nursing.
The nursing schools have relationships with businesses that employ nurses. The businesses are looking for the nursing licensure, and then they will mold the employee to the employer's demands. Being the right kind of employee is far more important. As far as I know, the generic BSN students' lack of clinical education/training didn't hamper their ability to find jobs. Business relationships is the key, not actual student preparation/ability.
I often notice a huge dichotomy between the job requirements for nursing positions I see advertised, and the calibre of the nurses I see working. I have come to believe, based on what I have seen/experienced, that knowledgeable, ethical, competent bedside practitioners; nurses who employ critical thinking and use the Nursing Process as the backbone of the care they provide, are not generally desired as employees. What I see preferred is a much dumbed down model; practicing nursing as merely a series of tasks and obedience to employer directives with minimal critical thinking.
To my knowledge, the nursing schools are responsible for these changes in nursing education, as I remember what I witnessed in my BSN Bridge program years ago. I remember the talk, then, of how nursing was moving out into the community, and how more nursing would be provided in the community in future, and of course, how nursing was moving towards the BSN. The huge push by nursing academia to elevate the nursing profession was taking place; the desire to increase the supply of Nurse Practitioners, and to raise the entry level to practice. None of this happened by accident.
We read here of nursing students in BSN programs complaining that their BSN program didn't teach them how to be a bedside nurse; that virtually the whole emphasis was on preparing them for NP school, and that they felt they had been cheated out of their education as they had gone to nursing school in order to learn the basics of being a nurse I.e. how to provide basic nursing care.
The consequence of all this is that patients suffer as nurses don't know how to provide nursing care.

I agree. In my bridge program, we we constantly told we were preparing for NP or CRNA. Many if us were seeing the writing on the wall of necessity of BSN minimum/preferred, and were doing it then, 2005 in my case. When I told my previous employer that I was pursuing my MSN, they automatically assumed that I was going for my NP. When I told them L/M, they asked why would I waste my time money. Too me not a waste. I got at WGU with no plans on L/M, just wanted in case MSN becomes a preferred, which in some cases it has, if you have experience. It, in no way/shape/form has made me a better nurse at the bedside

londonflo · Aug 3, 2020

On 8/1/2020 at 8:25 PM, Hoosier_RN said:
I don’t blame nursing instructors, per se, they are hired to teach a class by the model the school wishes. I

The philosophy of the college is chosen by the faculty who should be supporting it. I have been involved with the development of 3 programs and we discussed our beliefs and we came to an agreement. The nursing model is usually based on an established (published) nursing model. Does it revolutionize the delivery of nursing care? No. I worked with several models over my time in nursing: Sister Calista Roy, Dorthea Orem and Margery Gordon and I liked the way each organized nursing. As a nurse who graduated within in the dawning age of the identification of a nursing model and the establishment of the nursing process I felt there was something special there to describe what nurses do. It is indeed hard to respect anything other than that-- Okay let us speak to the all encompassing nursing theory that nursing should NOT use the medical model. A true nursing theory should focus on the issues that nurses identify, diagnose and care for and not on body systems. BUT nurses have NEVER supported the importance of our profession having its own theory. No wonder that nursing care is just a line item on the patient's bill.

I worked with one nurse (who said she never introduced herself as a nurse and was so proud of that) who reintroduced the medical model in her course, including a medical model assessment disrupting what the students had done before in their nursing assessments When I got to know her I explained that she should never accepted the job if she couldn't support the nursing department philosophy. Of course this didn't faze her. I found she had never worked as a nurse, but did have a nursing degree and her PhD was in physiology. She sought the nursing faculty job despite never working 1 day as a nurse. Was it any wonder she was not part of the packaging of the nursing department of her employer when it was sold to another school? . Oh, well she was found out when she had her nursing students do "oral" care plans. This insured there was no paper record of her "knowledge deficit".

Susie2310 · Aug 3, 2020

1 hour ago, londonflo said:
BUT nurses have NEVER supported the importance of our profession having its own theory. No wonder that nursing care is just a line item on the patient's bill.

I remember being exposed to a number of nursing theories, but I don't believe that nursing care being just a line item is due to nurses not supporting the profession having it's own theory. There are nurses who don't know how to provide basic nursing care. A number of nurses don't recognize the importance of using the Nursing Process, or even seem to know what it is. This also applies to Nursing Care Plans. These are the areas that define nursing practice. I believe these are the areas where nurses sabotage themselves.

subee, MSN, CRNA · Aug 3, 2020

I don't know enough to know why, but I do remember when hospitals depended on the labor of student nurses. Hospitals are spending more money than ever with extended orientations or residencies without being invested in nursing education. Is anyone else here old enough to remember the 5 year plan for nursing education? I interviewed at Cornell Hospital's school of nursing in 1972. They required 60 credits as a minimum for admission but the applicants usually had bachelor's because the program was so competitive. You then attended the hospital school (with Cornell instructors) for 3 years paying the low tuition diploma programs offered. Yes, you spent and extra year in college, BUT if you went to the first 2 years in a community college, it could be much cheaper than the standard 4 year program and your degree came from Cornell. Columbia also used the same model. Students graduated on Friday and hit the floor on Monday ready to work because of the extensive clinical hours. What happened when nursing education became so separated from hospitals? Some of you may know the answer to this. BTW, I was rejected with a previous BA degree because I had a C in chem. Right there at the interview, told I would have to re-take those 8 credits:( Ended up part-time at a private university but it still took 3 years to get the BSN.

Editorial Team / Admin · Aug 3, 2020

5 minutes ago, subee said:
You then attended the hospital school

And I think that's one of the biggest influences that have changed things. The hospitals are no longer invested in the schools.

HiddencatBSN, BSN · Aug 5, 2020

On 8/2/2020 at 5:10 PM, Hoosier_RN said:
There are reasons that graduates need the residencies that were not in place even 10 years ago. Many schools are not giving the needed skills to start out of the gate

Psychomotor skills depend so much on where you work tho. And with increased specialization and complexity in care, there’s just going to be a lot learned on the job.

Hospitals factor in to the equation: is it the school’s fault or the local health care community’s fault when none of the area hospitals allow students to place IVs? This was the standard in the city I went to school in, so one of the things hospitals had to be prepared to do was teach IV skills go new grads.

And as far as these months long to year long residencies go...my understanding is their intent is to ultimately decrease new grad turnover by providing some social support. My “residency” which lasted a year consisted of once a month meetings where we chatted with the other new nurses hired around the same time, shared concerns and frustrations, and maybe had a topic-based lecture or simulation. And then we did an EBP group project. I’ve worked one place where new grad residencies are actually a year of precepted orientation and this was a hospital work around to be able to hire the occasional, highly talented new grads into the ER when there was a state law prohibiting nurses from working in the ED with less than a year of experience.

My experience as an educator is fairly minimal but my main concern with my students’ clinical skills when they came to me was lack of appropriate clinical sites: like peds clinical taking place in a peds unit that took adults when they were low census (which was often) and not actually having peds patients to take care of.

I think there are schools that do a better or worse job of graduating nurses with a good basis for learning practice, but I think the expectation that nurses graduate ready to work with a 3 day orientation is antiquated, and a throwback to a time when care was simpler and there wasn’t as much focus on patient safety.

NAtoRN · Aug 5, 2020

As a new grad nurse who just worked my first 4 shifts on the floor with my preceptor, I completely agree. My clinicals did not provide sufficient experience and my school does not have the capstone at the end where you are one on on with a hospital nurse for multiple weeks. I am so thankful that I worked as a nurse assistant while I was in school; it was great experience, but I still have sooooo much to learn. Why aren't nursing schools run by hospitals anymore?

Hoosier_RN, MSN · Aug 5, 2020

2 hours ago, HiddencatBSN said:
Psychomotor skills depend so much on where you work tho. And with increased specialization and complexity in care, there’s just going to be a lot learned on the job.
Hospitals factor in to the equation: is it the school’s fault or the local health care community’s fault when none of the area hospitals allow students to place IVs? This was the standard in the city I went to school in, so one of the things hospitals had to be prepared to do was teach IV skills go new grads.
And as far as these months long to year long residencies go...my understanding is their intent is to ultimately decrease new grad turnover by providing some social support. My “residency” which lasted a year consisted of once a month meetings where we chatted with the other new nurses hired around the same time, shared concerns and frustrations, and maybe had a topic-based lecture or simulation. And then we did an EBP group project. I’ve worked one place where new grad residencies are actually a year of precepted orientation and this was a hospital work around to be able to hire the occasional, highly talented new grads into the ER when there was a state law prohibiting nurses from working in the ED with less than a year of experience.
My experience as an educator is fairly minimal but my main concern with my students’ clinical skills when they came to me was lack of appropriate clinical sites: like peds clinical taking place in a peds unit that took adults when they were low census (which was often) and not actually having peds patients to take care of.
I think there are schools that do a better or worse job of graduating nurses with a good basis for learning practice, but I think the expectation that nurses graduate ready to work with a 3 day orientation is antiquated, and a throwback to a time when care was simpler and there wasn’t as much focus on patient safety.

I graduated in 1993, and I do beg to differ, there has always been a focus on patient safety, that has always been the primary focus of nursing. In fact, as ratios have gotten worse, so I think that weakens your argument of patient safety. When I and my cohort left nursing school, we had been having 2-3 12 hour days a week of clinicals. We took a full patient load. When I graduated, I went straight into an ICU and was ready to work, even with multiple drips (yes we had them back in the stone age), we had learned the basics of time management, patient prioritization, etc. I had a week (3 12s) to learn charting and supply and room locations. We had 2 8 hour days of policy and HR activity. Our teammates on the floor offered support because there was decent staffing and time. Yes, some meds are different. Patient care isn't-starting an IV, administering meds regardless of route, feeding tube, Foley catheters, and basic ADLs are still the same. Many new nurses are coming out without even a basic knowledge of the HOW. They can answer the question of WHY and WHEN, because they needed to know for NCLEX. Maybe saw it done once in a sim lab. Most residencies are to cover the basics that should have been covered in school.

I was a preceptor up until I left the hospital and have friends who are unit managers or preceptors. We are amazed at level of basic patient care that isn't known. One reported that when she suggested repositioning a patient in ICU, she got a deer in the headlights look, asked "what do you mean", and then new nurse admitted she didn't know how/had never done that. But she knew all the meds/interactions the patient was on and how to set up the IV pump. Yippee Skippy, thats good to know, but the other is necessary as well. Other students, from other schools, pretty much the same. So in my opinion, schools are failing students in providing the basics for patients

Susie2310 · Aug 5, 2020

8 hours ago, Hoosier_RN said:
I was a preceptor up until I left the hospital and have friends who are unit managers or preceptors. We are amazed at level of basic patient care that isn't known. One reported that when she suggested repositioning a patient in ICU, she got a deer in the headlights look, asked "what do you mean", and then new nurse admitted she didn't know how/had never done that. But she knew all the meds/interactions the patient was on and how to set up the IV pump. Yippee Skippy, thats good to know, but the other is necessary as well. Other students, from other schools, pretty much the same. So in my opinion, schools are failing students in providing the basics for patients

I agree. I would add to this, knowledge deficit in assisting patients with hygiene needs, cleaning incontinence, assisting patients when they have diarrhea, changing patients' gowns, and changing the patient's bed linens when needed.

Some nurses also appear to have an attitude problem, as I have seen nurses act as though they are above doing these things, actually behaving as though they are offended by being asked, for example, to clean up urine the patient has spilled on themself while using their urinal, and neglecting to change the patient's urine covered sheets, instead just bringing the patient a towel and letting the patient sit in urine covered, wet sheets.

When patients spill urine on themselves, while negotiating the not so easy task of using a urinal, and they ask for help, please help the patient instead of acting offended at having to look at/touch/cleanse their genital area. Patients' don't usually spill urine on themselves to titilate the nurse; they do this because they couldn't help it and they need assistance. Nurses, it is part of your job to do these things even if you were never taught this. Urine burns the skin and causes skin breakdown (as does faeces).