I've seen that phrase a lot, and I really don't understand it. I'm not being snarky here...I sincerely don't get what that means.
For example, working with difficult people and noncompliant patients is not something taught in nursing schools, so it's NOT a textbook thing...not taught in lecture, but it certainly comes up in clinicals. It's mainly the real world of nursing, but we might have seen it on the floors during our education. Therefore, there is no "vs." about it.
Is it because in "textbook" nursing, the assumption is that every patient is compliant, every role does their job without question, and when you get on the floor, those assumptions no longer apply?
That's really the only thing I can come up with.
I guess my question comes from nursing friends who said to me after I did an FB post that I got a job, "Forget everything you learned in school. You're in the real world now." I use what I learned in school every single day: pharmacology, assessment, pathophys. When I have questions about nursing judgement, my basis for those questions is what I learned in school, although school didn't teach me everything, of course, which is the reason I'm asking the questions in the first place.
How do you define that phrase? What do you really mean when you say it?
The blueprint approach also pretty much excludes priority setting: you learn pathophysiology and what to do about it ... but not how to prioritize/coordinate multiple patients' pathophysiology within the framework of multiple systems.
I did get that, somewhat, in my education. My entire last semester seemed to focus highly on prioritization of patient care needs based on patho and safety.
Last night, I had a pt situation that seemed entirely psychosocial (which I attempted to address earlier in the shift with moderate results), but there was an element of safety introduced later on with the same pt. When I recognized the safety issue, I mentally pushed it up into a higher priority.
ETA: Sometimes "the book" is only a starting point. And sometimes, you throw out the entire book.
Age, maturity, personality and previous life experiences have a great deal to do with whether the textbook vs. real world learning curve will be slight or steep.
For me, I feel like this message board has been a wonderful resource for preparing for the textbook vs. real world stuff. I tend to be a one of those rigid, by the books people and as flexible as I try to be, I know I'll need a lot of preparation ahead of time before I get to "real world". Glad to have this place to get at least a little bit of "warning" ahead of time! Thank you to all of the BTDTs who are happy to help us Not There Yets!
I would also throw financial, social and practical limitations into the mix. Say that a patient (in this case, my father) presents to the doctor's office with classic s/s of thrombophlebitis. The textbook would dictate certain inpatient diagnostic tests, bedrest on a med/surg unit, IV access, anti-coagulant therapy, etc.
Real world, we were not insured and my dad was the sole proprietor of a family business who was not about to miss a day of work. The compromise: crutches to keep him off that leg, outpatient diagnostics, oral medications, a promise that he would not drive a car until OK'd by the doctor and an unspoken agreement not to sue the practical and understanding doctor who accomodated his limitations rather than insist on care that was not realistic.
I would also throw financial, social and practical limitations into the mix. Say that a patient (in this case, my father) presents to the doctor's office with classic s/s of thrombophlebitis. The textbook would dictate certain inpatient diagnostic tests, bedrest on a med/surg unit, IV access, anti-coagulant therapy, etc.
Real world, we were not insured and my dad was the sole proprietor of a family business who was not about to miss a day of work. The compromise: crutches to keep him off that leg, outpatient diagnostics, oral medications, a promise that he would not drive a car until OK'd by the doctor and an unspoken agreement not to sue the practical and understanding doctor who accomodated his limitations rather than insist on care that was not realistic.
This would be the experience of my decades-long friend who is an RN in a surgeon's office. (She, however, has never used the phrase that inspired this thread.) We have had long talks about nursing and very similar pre-op/post-op situations have been brought up. I can see how her experience plays a vital role in her confidence, patient advocacy, compassion, understanding, and problem-solving ability in situations like this. It can't be taught; it can only be learned over time. No wonder she's one of my role models.
I feel like this is a saying that catches on with the students in your class that you know aren't going to be a good fit for a nursing career. The ones with little or no patient care experience but they are dead set on becoming a nurse! ($$$!)
These people think that the floor should be just like textbook where everything is quiet and as you mentioned, compliant.
Of course this is a fantasy world for anyone that has worked healthcare :). I agree with you though, there is no Versus, it is all the same thing -- some people have just prepared themselves for the job better than others.
The ones that jump in and feel lost/hectic because they have never done this before are probably the ones that felt that way going through nursing school courses (so they probably don't have that much to "forget" from the textbook anyway!)
I don't feel there is any reason you shouldn't attempt to apply your education to every case, every time. We went to school for a reason, not so we can just wing it once we get to the floor....Even as a CNA Nursing Student -- RN's were impressed with my knowledge base and there were a few I honestly felt more educated than (only a few, and they would probably be the ones that said "Forget it all, real world starts now"
That's THEIR real world, the world where they didn't actually learn anything to carry over into their profession.
I like what you said here, it brought back memories of my fellow students who struggled all thru class, most did not graduate, but there were one or twothat made it to graduation. I was concentrating on my own struggles, but mine were juggling school, work etc. ONce I graduated, I just made sure, as I still dotoday, to make sure I listen and learn every day. There is no day, as a real world nurse, that you "graduate" and know all that you need to know. There are good and bad days. Every challenge is an opportunity, I struggle much more with difficult non-nursing staff (support staff, as they like to call themselves) than with the patients. The patients are our bread and butter, their needs should supercede ours. Iwould be a difficult patient too if the nurse didn't tell me what they were doing to me, ie sticking my arm with a needle, inserting a foley, drawing my blood etc. It isn't easy tobe in pain, and be sick and still be your own advocate. If you are only doing it for the money....it tends to show right thru, which leads to difficult patient behaviors as well.
Nursing school gives u the basics of nursing and prepares you for a nursing career but, you have to go out and work in the field in order to get experience and the rest of ur knowledge. Nursing school just prepares you.
Sterile foley insertion. all the steps, perfectly organized.
Real world..
The pt is so edematous you can't find the right place to put it! Or, the pt is AMS and combative and u have to just be as sterile as possible.
Stuff happens. That's the way I look at it
Haha! This reminds me of the clinical day that we nursing students observed a med/surg nurse do a dressing change. It was a combative patient, incontinent of bowel and bladder, inner thigh wound, etc., etc. Of course, the dressing change was a constant struggle for the nurse. OF COURSE, sterility was compromised but the nurse (in my memory) did the best that she could. Somehow, one of us managed to ask her a question about the sterility of the dressing change without offending her, and her response was something along the lines of "well, I did the best that I could and it was as sterile as I could make it."
Of course, we all hightailed it back to the instructor, righteously indignant with our tales of dressing change sterility being a continuum, not an absolute. Our instructor was appalled. To this day, I wonder why that instructor didn't use this as a teaching lesson about the real world vs. nursing school, but she didn't. Perhaps she had been too long in the ivory tower.
Nursing school gives u the basics of nursing and prepares you for a nursing career but, you have to go out and work in the field in order to get experience and the rest of ur knowledge. Nursing school just prepares you.
You will know when you start working. The pt who is always in 10/10 pain (even when sleeping, making phone calls) demanding dilaudid every 2 hours.... The patient teaching to the patient who could care less...
Here is one good example that I remember where textbook clashed with real world:
Not my pt, pt of TBRN (textbook RN) - Pt is very difficult stick and has just one 22 G available. Pt H+H was dropping, MD on the floor ordered blood. After multiple attempts at sticking her for something bigger (16-18 G), TBRN could not gain appropriate IV access and called the MD. The MD said thats fine, and give the blood anyway. TBRN refused. MD reiterated why she needed blood now, and that they could get a PICC in the AM, TBRN fought tooth and nail about this. It needs to be an 18 G or larger!
How do you think babies and neonates recieve blood?
Someone else ended up giving the blood, no ill effects from administration of it. The concern is with cell destruction being administered through such a small gauge needle, although it is still possible to give it.
Moral of the story: Nursing is dynamic. There is no black and white. Never say never, and never say always. You are dealt your cards, you find your play - in the end, you do the best for your patients and can't always stick to the book.
quick cathing suggestion: tuck the last prep-soaked cotton ball into the introitus. not deep, just enough to be a place-holder. that way if the cath slips downward when you're trying to find the urethra, you don't contaminate it in the lady parts and have to start over.
Moral of the story: Nursing is dynamic. There is no black and white. Never say never, and never say always. You are dealt your cards, you find your play - in the end, you do the best for your patients and can't always stick to the book.
Great example with the blood!
Yeah, I always thought of "text book" as the perfect world, where you do everything you are supposed to do exactly when you are supposed to do it.
You know, in the "text book" world all documentation would be done exactly on time, one would pass meds within the hour mark, turn patients exactly q2 hours, assess pain 1 hour post medication, and spend all kinds of time educating the patient, knowing that they will be completely complient upon discharge. All the things you fully intend to do knowing they are in the best interest of the patient. And all of this would be fine if you only had one patient!
In the real world, you are short staffed, have to deal with admissions and discharges, patients become unstable, pharmacy is slow sending up meds, family demands answers to questions, MDs dont' return pages, and all of your patients are incontinent with C-Diff. You learn quick to prioritize, try to keep your sanity, CYA with documentation, and be proud that all of your patients received the best care you could provide and you survived another shift.
dudette10, MSN, RN
3,530 Posts
I did get that, somewhat, in my education. My entire last semester seemed to focus highly on prioritization of patient care needs based on patho and safety.
Last night, I had a pt situation that seemed entirely psychosocial (which I attempted to address earlier in the shift with moderate results), but there was an element of safety introduced later on with the same pt. When I recognized the safety issue, I mentally pushed it up into a higher priority.
Agreed.