Textbook nursing vs. real world nursing.

[dudette10]

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?

[A&OxNone, MSN, RN]

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.

good advice!! i had a man in the er last week with fluid overload, and his testicles were about a smidge away from being the size of a basketball, hard, and weeping fluid. anyways, since he was so swollen, his member was retracted into his testicles. 45 minutes and 4 nurses later, we couldn't get a foley in him to save our lives. any tricks up your sleeve in that case?

[wazeout]

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 can understand what you're saying from a "dip your toe in the water" approach to see if you can deal with the environment of healthcare, but saying that YOU know people "with little to no patient care experience" will not be a good fit for a nursing career is just your unproven opinion--anecdotes aside.

Working as a CNA before going to nursing school doesn't make you a more experienced registered nurse once you finish school and pass the nclex. In fact it doesn't even count as RN experience at all. It's not like you can negotiate a higher starting wage based on that experience, let alone even get an RN job based off it.

I mean really, you never hear people say this about PT's, OT's or MD's only RN's. The truth is that once you've finished school and become licensed in whatever healthcare postition you've been trained in, then you can practice what you've learned in school, and continuously build upon that knowledge in real (life) time, which will always present something new and challenging.

[brownbook]

When I studied to be moderate sedation qualified the "text book" had indepth details about basing dosing amount per patients weight, mg/kg, and giving the versed, fentanyl, demerol, etc. slowly over 1 - 2 minutes.

Ha, ha, the real world of GI nursing. Unless the patient is a little old lady or man you give the same starting amount to everyone. The patient is monitored, on O2, etc. and you are PUSHING the sedatives in fast. If I gave the drugs as slowly as recommended per the text book the MD would be done with an EGD before the first drug was in!

[RNperdiem, RN]

Textbook nursing: delegate to the CNA as needed, and the work gets done. Nursing school made delegation sound easy.

Reality: To delegate you need to find someone to delegate to. Some CNAs are even busier than we are, and others are off on meal/snack/computer/smoke break when you need them.

[dudette10, MSN, RN]

Textbook nursing: delegate to the CNA as needed, and the work gets done. Nursing school made delegation sound easy.

Reality: To delegate you need to find someone to delegate to. Some CNAs are even busier than we are, and others are off on meal/snack/computer/smoke break when you need them.

IME at my workplace, the CNAs are great. They are very busy with their tasks, and they do a good job of patient care and notifying the nurses when something isn't quite right. In the short time I've worked there, I've set up a good relationship with them, but I didn't focus on the relationship-building solely so they would do stuff when I asked them. I did it because the patients deserve a partnership between the CNAs and the nurses, and the patients have benefited from it. When two people do total care on a patient, the patient can be moved more easily, cleaned up more thoroughly, and any discomfort is very short-lived with two sets of hands doing so.

I guess I'm lucky that it's been "textbook" for me.

[diva rn, BSN, RN]

I am one who believes that nursing school just gives the bare basics...and not too many at that....

I think nursing is an on the job learning...I just know in 18 years of bedside in mainly ICU, PICU, and Hospice (with a little school nursing and a DON gig thrown in) that I learned something new every. single. day.

*and yes, there is another shoe, and sometimes it does drop..but you pick it up and put it back on and run down that hall again...sometimes there is no time to even tie that shoe!

But every day it gets easier and you are more comfortable...I think it takes a good year before you are ok and 2 years before you really know what you are doing...maybe more or less-depends on person and the specialty....

we were all there and made it thru...you will do fine...

[xtxrn, ASN, RN]

I used to tell students that school tells you how to not kill someone on purpose. The rest comes from experience- and not just a year or two- that's not a slam to new nurses- it's just a LOT of information to learn how to apply (knowledge is great- application makes it worth something :)).

And, while the books tell you how things are done ideally, you end up finding ways to get the job done just as well, but tweaked to your own strengths. I learned how to put in IVs w/o gloves (back then, there was a box of gloves at the desk- and you ran for them if you needed them- mostly for code brown situations). My "feeler finger" was critical for the non-visible veins. When the whole glove business started, I had to comply- but I poked my "feeler finger" through a slot, felt for the vein if it wasn't visible, and stuck said finger back into the glove. I could have felt for the vein and then put gloves on, but didn't want to have the tourniquet on any longer than necessary. :)

As has been said, books talk about ideal situations. The real world puts in the individual human components and behaviors. (books aren't all that good about making the topic applicable to a live human- always reminded me of the dummies in the practice lab ).

[MamaKitty13214]

• The Real World is not a well-ordered place
  
• You can't control everything
  
• You do the best you can within the Standard of Care for Nursing Practice and according to institutional policy
  
• You document carefully and clearly, especially when there is non-compliance, non-cooperation, or "the system" poses barriers (i.e. docs won't give requested orders, supplies can't be obtained, etc)
  

[nursk8]

Good advice!! I had a man in the ER last week with fluid overload, and his testicles were about a smidge away from being the size of a basketball, hard, and weeping fluid. Anyways, since he was so swollen, his member was retracted into his testicles. 45 minutes and 4 nurses later, we couldn't get a foley in him to save our lives. Any tricks up your sleeve in that case?

with another nurse or aide helping you, they should put their thumbs and index fingers together making a triangular shape and with their weight push down all around where the member should be. it should make the member "pop out". i have done this before successfully with another RN doing the cath. He was amazed at that lol!

he called the other nurses in to have me show them how to cath a man whose member was retracted because of edema or weight. This was back in my LVN days before i went back to school for my RN.

[xtxrn, ASN, RN]

Way back when- they may still use these, but when I stopped working, they'd been scarce for a while-- external catheters for men (for a while they made them for women- big disaster) were often used.... I worked with a nurse who could find a member where it only looked like a second naval lived :) She could make them "stick", too- which was really amazing :) THAT was never in any book

Babies with congenital malformations, ambiguous genitalia, etc- you have to punt sometimes to get things done. (all without just picking the kid up and crying sometimes).

With blood administration, I think the speed is the big deal with the gauge of the IV- my blood comes OUT just fine with a 31g insulin needle or lancet :)

[Eaglelady]

In nursing school they teach you how to put an IV in a patient and make it look easy but in the real world you have drug addicts and alcoholics and others where they have no veins or patients that are edematous , or veins that blow just when they see the needle coming towards them this is textbook vs real world :)

[pockunit, ADN, RN]

How about this: the nurse on the floor performs a procedure in a way you would be failed for doing, but that's the classroom and this is the floor and you simply cannot do things on the floor the way they train you to do in school. Flush after every med in a tube feeding on a pt with CHF? Probably not. Forget to do it in skills check-off? Big fat F.