Stop the preceptor madness!

[Rocknurse]

I just counted 21 posts on the main page alone that were all NP students looking for preceptors. How long is this madness going to continue? Why are schools not providing preceptors for their students? My school finds all our preceptors for us, as it should be, and it was one of the requirements I had when choosing a program. If we stop applying to schools that won't find you your preceptor then they'll be forced to adapt! No professional should have to beg.

[myoglobin, ASN, BSN, MSN]

Also getting back to the point about the "poor quality" school in your area. How do you know that they are of poor quality. How do you know that the nurse who graduated and had to be let go for negligence was actually at fault? Was there a comprehensive, fair investigation? If even this nurse was at fault might have it not been a "system failure" (and here I reference back to the To Err is Human studies and their subsequent followups which argue that most errors are due more to systemic system failures than individuals). Furthermore, I have seen numerous examples where nurses (and I believe the same applies to NP clinicians) get blamed for errors and negligence set in place by MD providers. For example my SO has already seen dozens of examples both in her clinical's and her first year working as a provider of multiple SSRI's on the same patient prescribed at dosages that exceed guidelines. In addition, she has seen patients on drugs like lithium where the levels haven't been checked in years, and on multiple escalating dosages of benzo's for patients with depression/anxiety. In all of these cases "she" could have potentially been blamed for renewing these prescriptions written and initiated often for many months (years?) by MD board certified psychiatrists with many years of experience.

Indeed, she faced harsh "criticism" on the few occasions that she directly questioned their reasoning rather than simply declining/altering the patients medications. Indeed, if the patient whom she altered medications upon suffered a destablization resulting in suicide or self harm she might have been "seen as negligent" because hers was the last point of contact, despite the fact that she was terminating a prescription program far out of established, standard of practice guidelines. My point is that you shouldn't assume that the nurse (nurses) that you reference were acting in the wrong or that they represent the institution as a whole negatively. Indeed, I would argue that the "trend" if there is one in your area not to hire nurses from that institution may represent an unfair "elitism" and indeed be a manifestation of "horizontal violence" of a sort. Which aspect of national guidelines is your referenced institution failing to meet with regard to their students? To indite with "broad strokes" is scarcely preferable to stopping someone and frisking them because they happen to be of a certain skin color or have a less than wealthy appearance. In both instances there is a loss of due process and intrinsic constitutional protections. Perhaps, if greater efforts were made to focus on the system where the supposed acts of negligence occurred and less on the specific individuals then we would have a more pleasant, safer environment in which to practice.

[BostonFNP, APRN]

Again, my goal is to be mediocre, follow the law, and to live in Hawaii.

If this is truly your goal, truly what you feel all your perspective patients one day deserve, perhaps it is best to stop posting about it. It looks poorly on our profession as a whole.

Indeed, I would argue that the "trend" if there is one in your area not to hire nurses from that institution may represent an unfair "elitism" and indeed be a manifestation of "horizontal violence" of a sort.

Yes, this brand new trend of hiring from the best possible institutions is obviously lateral violence an elitism. Are you really serious with this kind of comment?

[Jules A, MSN]

In addition, she has seen patients on drugs like lithium where the levels haven't been checked in years, and on multiple escalating dosages of benzo's for patients with depression/anxiety. In all of these cases "she" could have potentially been blamed for renewing these prescriptions written and initiated often for many months (years?) by MD board certified psychiatrists with many years of experience.

Indeed, she faced harsh "criticism" on the few occasions that she directly questioned their reasoning rather than simply declining/altering the patients medications. Indeed, if the patient whom she altered medications upon suffered a destablization resulting in suicide or self harm she might have been "seen as negligent" because hers was the last point of contact, despite the fact that she was terminating a prescription program far out of established, standard of practice guidelines. My point is that you shouldn't assume that the nurse (nurses) that you reference were acting in the wrong or that they represent the institution as a whole negatively.

You bring up some interesting points that might be helpful for other new NPs to consider as they move forward. It is not uncommon in my experience for NPs to tend to continue a totally inappropriate regimen rather than upset the boat and as you pointed out try hiding behind that fact when there is an adverse outcome, which in my non-legal-professional opinion won't fly in a court room. Once you prescribe for them they are your responsibility. Do not take on a patient you feel you can't safely manage and just because you see someone for an evaluation, and bill for that evaluation, does in no way obligate you to prescribe or continue one single medication. You have to thoroughly document and we document that we provided a list of other area providers but again this is not your patient just because you saw them for an evaluation. In cases of a PCP referral I will phone them and say thanks but no thanks to an unsafe turf and the aggravation of dealing with with their poor choices. A good example of this is the ever present cases of a PCP who has been prescribing a horrid benzo regimen long term and now the patient needs to seen by an "expert" because they are clearly dependent and things are out of control ie. requesting early refills, appears obtunded, crying/threatening when discussing reductions etc. particularly in these cases there may be a legitimate need for inpatient detox however whether you take on this patient or not is your choice and not your obligation because they wandered into your office. If your employer is so focused on retaining any patient who shows up regardless of if for financial or "because if we don't care for them who will?" you are putting your license at risk. Where I work I can appropriately discharge or refuse to take on any patient I feel I am unable to safely and appropriately care for no matter what the reasons.

The bottom line for the above scenario is the last provider absolutely becomes responsible and negligent if they continue an egregious regimen without either attempting to make appropriate, safe changes or as your girlfriend did consult the previous provider and document thoroughly the risks vs benefits of continuing the present regimen. Also as you pointed out if you make a single change and things go south regardless of if it had anything to do with the likely benign reduction of Prozac from 80mg to 70mg you are going to be a target for lawyers so my personal opinion is to consider all of the above before you accept and treat a patient which again that can be after an evaluation.

The incidents you cite are absolutely reason for concern and I personally would not work with incompetent MDs, nor MDs who get snippy if I appropriately ask for clarification, because it does overflow on me the minute I'm asked to do something with their patient. On acute units everyone sort of does their own thing so not as big a deal. I will often write something like "continue to monitor VPA: at present above recommended maximum dose, no s/s toxicity, per patient well tolerated with positive effect" to cover me for the time I'm covering for their physician but once the patient goes back to them although everyone including the janitor gets pulled into law suits its unlikely that would be considered negligence especially because you charted it for the attending to address.

[myoglobin, ASN, BSN, MSN]

I also believe that a challenge in our differing perspectives is regional. For example I am continually "shocked" even after eight years how deficient health care is in central Florida (specifically hospitals and primary care/psych providers) are relative to Indiana. Now Indiana could scarcely be considered a paragon of Utopian health ideals. However, the PCU where I worked had a ratio limit of four to one and we never had less than two techs on the floor. Our ICU at Methodist had a dedicated tech, dedicated RT's, and secretaries. None of these exist at the level two, trauma center where I now work. We are expected to care for 400lb, vented patients with cervical spinal fractures, answer phones, open doors, and fill out a myriad of paperwork. On those occasions that I pick up shifts (relatively rare) with an agency affiliated with my hospital system I've had six to one PCU assignments and am constantly tripled in ICU. Last time I was sent to ER (as an ICU nurse) where I had two critical vented patients one of whom turned out to have been in PEA (on hemodialysis no less) for an unknown amount of time prior to my shift starting (there was no arterial line and he was vented). After a short code I was told I could give the wife about 30 minutes to visit and then I would have to clean the room myself since they don't have housekeeping. I then got a replacement patient with a drip (chronotropin for symptomatic bradycardia) that I couldn't obtain for many hours since the pharmacist had gone home for the evening.

We never turn away patients and will admit critically ill clients to PCU or keep them in the ER (where they will often have six or more to one even with post TPA or Baker act /high level suicide risk clients).

n the psych offices where my SO did clinical's (as did University of Central Florida medical school students and NP students) SECRETARIES would continue meds in many instances when there were NO providers (NP's, PA, MD's) to be had anywhere in the office. EVERY provider that I'm aware of (primary and psych) leaves signed prescription pads around because until this year PA's and NP's could not have prescriptive authority for controlled substances even with physician oversight (and because it is cheaper than actually reviewing yourself if you are the MD). It is not uncommon for psych providers (including where my SO works now as an NP) to cancel 30 to 50% of their appointments with little or no notice to the patient, because they don't have the providers to see them or tell them they must drive to an office an hour further away to see a provider. There are NO translators save for the "blue phones" which often don't work despite at least 30% of the clientele being Spanish speaking only. Did I mention when I used to work "overflow" in my hospital that we would put up to four patients in small utility rooms on ER cots (at least the ratios were capped at four to one so they probably actually got better care) with acuity going up to PCU? And yet our hospital consistently ranks in the top 30 in the nation for gross revenues for private hospitals (our actual hospital not the chain which ranks number one). Our town isn't in the top 30 and our "wealth index" probably wouldn't make the top 200 . How is that possible?

Let me say also that my first job here for about eight months was with Florida Hospital a non profit, and it was only slightly better. So it isn't just a "for profit" things.

I've actually given a speech to more than one newer resident doctor or nurse who expresses exasperation and amazement over some unbelievable element of our system (like not having working pulse oximetry cords despite purchasing a 20K plus pupil measuring device and three new Artic Suns with no pads so they can actually be used) that they need to watch Captain America's Winter Solder and understand that they work for Hydra, they have indeed sold their soul and abandon hope all ye who enter. These things are not aberrations but part of the business plan. Although, they initially think me a madman, many have come to me a couple of years later agreeing. What makes it worse we are constantly winning "safety awards" and most ethical company awards and top marks from Joint Commission. Heck, our once CEO presided when we received the largest fine at the time of any hospital in American History (several billion) and went on to become Governor. Lest you blame Republicans only our company wrote one of the strongest amicus briefs supporting Obama Care in the 5-4 Sebelius vs National Federation of Independent Businesses. These may not go to your point(s) about attitudes toward education directly, but they do help shape perspectives. Simply, following the law and usually staying within guidelines would make someone so darn exemplary that they would probably be run out of town.

[myoglobin, ASN, BSN, MSN]

If this is truly your goal, truly what you feel all your perspective patients one day deserve, perhaps it is best to stop posting about it. It looks poorly on our profession as a whole.

Yes, this brand new trend of hiring from the best possible institutions is obviously lateral violence an elitism. Are you really serious with this kind of comment?

Yes I am quite serious. Some of the best nurses that I work with come from a local institution in particular which has at best a "marginal" reputation (NCLEX pass rate less than 50% and they specialize in those who speak English as a second language). I am arguing for a perspective that appreciates the unique contributions that a diverse workforce can bring. We all have unique gifts and weaknesses. I literally cannot smile unless it is spontaneous, and literally couldn't start an IV on Arnold S. after he ate a plate of pasta. BUT, I've read medical journals since I was about ten at the expense of watching sports, going on dates and pretty much everything else save for video games, work with great focus, move like a banshee in helping my coworkers and receive more positive feedback from patients than almost anyone else. Others (such as the two nurses who graduated from the institution I am referencing) are not academic geniuses and might believe that the Journal Nature has great outdoor photos, but their attitudes literally exude light, their patients are beautiful (in terms of bathing) and they could start IV's on Keith Richards after he had gone three days without eating. Their non judgmental attitudes and sincere desire to learn/excel make me a better nurse and make me want to do a good job for them in addition to my patients. Look, what I'm saying here is "what about the problem institution(s) that you reference makes them intrinsically deficient?". If they are accredited and their graduates pass boards at a reasonable rate what makes their students less worthy of consideration?

Again, I will reference the multitude of studies and meta-analyses that show equal or superior outcomes for NP's as compared to MD's (and much better patient satisfaction scores). And yet I would wager than the average educational resume, and indeed standard intelligence test, SAT and almost every other academic measure would strongly favor MD's over NP's as a group. Yet it doesn't translate to superior outcomes at least in the recognized studies accepted by the Institute of Medicine, the Robert Woods Johnson Foundation and many other well regarded institutions. So yes I am serious about alleging possible elitism which can be tantamount to an expression of horizontal violence or even worse classism. Now if you tell me that they (the schools in question) are actually "cheating" the system in some salient way so as not to actually meet guidelines (not actually offering the three P courses for example, or crediting clinical hours not worked in a systematic manner) then I would say they should lose their accredited status. However, I would wager many of those students have worked hard and what's more is their graduates are willing to precept newer students that only strengthens my conviction as to the sincere nature of their desire to excel and contribute to a positive nursing future.

I appreciate your perspectives how ever much I might disagree with them and believe that they certainly reflect a sizable portion of nurses perhaps the majority. Whether or not either of us reflect positively on the field of nursing is probably a matter of perspective. What's important is that we live in a place where free expression is still possible without overt fear and we enjoy a free forum with which to make such an expression.

[llg, PhD, RN]

Sure there are. Clamp down on the number of on-line nursing graduate programs. Require schools to provide vetted preceptors who are compensated by the school. In the B&M graduate program I attended, all of the clinical instruction was provided by clinical instructors who were at least part-time faculty of the school (joint appointments between the school and the clinical site).

But that's not going to happen, because nearly everyone in nursing apparently wants to be able to get a graduate degree in the privacy of their own home, in their jammies, without any significant inconvenience. It's no wonder other academic and clinical disciplines don't take nursing v. seriously.

Since I can't "like" this multiple times, I decided to quote this post to show how much I agree with it.

[BostonFNP, APRN]

Some of the best nurses that I work with come from a local institution in particular which has at best a "marginal" reputation (NCLEX pass rate less than 50% and they specialize in those who speak English as a second language).

First of all, if the NCLEX pass rate is less than 50% the school could not maintain accreditation.

Second, I think you misunderstand our point here: we are talking about large numbers not individuals. I am sure your anecdotes are compelling, however, there are always outliers (great nurses come from horrible schools and horrible nurses come from great schools).

Again, I will reference the multitude of studies and meta-analyses that show equal or superior outcomes for NP's as compared to MD's (and much better patient satisfaction scores).

As the NP workforce becomes more diluted with poorly trained providers do you think those outcomes studies with be affected? That's what we are trying to prevent: the first study that shows inferior outcomes for NPs is going to have a drastic impact on our profession. We need to be proactive about this.

Now if you tell me that they (the schools in question) are actually "cheating" the system in some salient way so as not to actually meet guidelines (not actually offering the three P courses for example, or crediting clinical hours not worked in a systematic manner) then I would say they should lose their accredited status. However, I would wager many of those students have worked hard and what's more is their graduates are willing to precept newer students that only strengthens my conviction as to the sincere nature of their desire to excel and contribute to a positive nursing future.

This has been going on for quite awhile (cheating on hours, becoming more lenient with what constitutes IM/OB/PED), and as above, it is concerning for the future of our profession. Once you spend some time in clinical practice it may become more clear to you, but ensuring that student NPs have quality clinical education is extremely important to continuation of quality care being provided by NPs.

[subee, MSN, CRNA]

First of all, if the NCLEX pass rate is less than 50% the school could not maintain accreditation.

Second, I think you misunderstand our point here: we are talking about large numbers not individuals. I am sure your anecdotes are compelling, however, there are always outliers (great nurses come from horrible schools and horrible nurses come from great schools).

As the NP workforce becomes more diluted with poorly trained providers do you think those outcomes studies with be affected? That's what we are trying to prevent: the first study that shows inferior outcomes for NPs is going to have a drastic impact on our profession. We need to be proactive about this.

This has been going on for quite awhile (cheating on hours, becoming more lenient with what constitutes IM/OB/PED), and as above, it is concerning for the future of our profession. Once you spend some time in clinical practice it may become more clear to you, but ensuring that student NPs have quality clinical education is extremely important to continuation of quality care being provided by NPs.[/QUOT

Yessss! We have to be better practitioners just to survive the politics of billing and payment, and the right ti maintain the privilege of doing both. Being a member of the APRN profession is a privilege, not a right. Also, as a boomer who only sees a doc for the yearly Medicare physical (taxpayer ripoff), I don't believe that our generation will supply the volume of cases that our cigarette smoking, physically adverse parents required. Don't underestimate us:)

[LessValuableNinja]

I "feel" that "quotations" are "used too much" in this "thread."

[myoglobin, ASN, BSN, MSN]

The program that I reference may or not maintain their status in fact they have been placed on probation at least once that I am aware. However, my point is that it is difficult to predict what sort of nurse someone will be based upon where they graduate. Also, we all make unique contributions that should be celebrated. When people strive for more education it is a cause to be applauded. Of course schools should offer excellent education but not at the expense of opportunities.

[BostonFNP, APRN]

However, my point is that it is difficult to predict what sort of nurse someone will be based upon where they graduate. Also, we all make unique contributions that should be celebrated. When people strive for more education it is a cause to be applauded. Of course schools should offer excellent education but not at the expense of opportunities.

It's not, in aggregate, difficult to predict what sort of nurse someone will be. If 50% of a program's students are not passing the NCLEX we can predict at least 50% of them lack the basic competency to practice.

Diversity is important but the provider role isn't for everyone.

[myoglobin, ASN, BSN, MSN]

I differ in that it is my perspective that predicting "what sort of nurses someone will be" goes far beyond physiology, pharmacology and nursing skills. Yes, there is a floor which should be met (the NCLEX) for RN's and certifications for NP's with regard to clinical knowledge. However, the contributions that nurses and clinicians make are far more complex and impossible to quantify. Caring, compassion, love towards patients and coworkers, patience, listening, empathy, these are traits scarcely measured by your tests and I would argue form a vast part of why NP's do well in studies of efficacy, patient satisfaction and outcomes. Materialistic determinism and its soulless dogma may dominate academia, but it does not account for the majesty of the human condition. When we fail to consider nurses who have passed their boards primarily because of where thy attended school we denigrate the very essence of what makes nursing special and discourage working nurses from going back to further their education at institutions that would make this more possible. This constitutes not only the sort of horizontal violence that motivate dozens if not hundreds of threads on this forum, but also denies future patients and co-workers from the benefits that could be enjoyed from working with wonderful clinicians.

We need diversity not for the MIT, Harvard or other top tier graduate with a 140 IQ fortunate enough to matriculate from a background that has cultivated their intrinsic advantages, but rather for the ordinary individual who has endeavored to master the basics and has a sincere desire to better themselves and serve others. I accept the validity of your perspective from an intellectual standpoint, but declare it spiritually bankrupt. Even in my own modest career I've had two preceptors tell me that I wasn't fit for nursing at my first two ICU jobs causing me to be "turned out" to PCU/Med surgical units emotionally devastated. Had I listened to them I suppose I would have taken my 100K debt and ASN degree and applied for disability or continued my career as a minimally paid server. Yet here I stand eight years later and despite my infinite shortcomings firmly established in the conviction that I've been able to make a contribution to coworkers and patients. With the grace of God, myself and others will continue to be afforded the opportunity to further our careers, educations, and opportunities to serve. I suppose I should thank you for asking me to keep silent since now the very gates of HeXX will be ripped asunder, Cerberus unleashed from his infernal leash, and Trump's Twitter account ripped from his hands before I cease presenting an alternative perspective.