What are you learning in nursing school?

TheSquire, DNP, APRN, NP · May 12, 2009

I'm a second-quarter master's entry student, so I'm a little bit weird compared to everyone else around here. However, this is what I've been learned so far.

In my first quarter, I learned how to do the basic tasks that usually get pawned off onto unlicensed assistive personnel: bedbaths, bed changing, basic assessment. I also learned how to do a basic assessment (at the APN level - something I'll be continuing next quarter) and took pharmacology, which is something that will be continually reinforced through the rest of my nursing career.

This quarter is my med-surg quarter, and it's in this quarter that we've started to go over basic labs, ekgs, etc. While there are a bazilion and one tests out there, there are things like Basic Metabolic Profiles and Complete Blood Counts that everyone is taught and supposed to know - whether or not it sticks is something else.

As for "Are you actually learning to recognize, understand, diagnose, and treat disease?" RNs NEVER make medical diagnoses. Ever. It is outside the scope of practice for an RN. We may have to beat residents upside their heads with our patients' signs and symptoms on occasion to get them to make a diagnosis, but we do not make medical diagnoses on our own unless/until we complete a master's-level or higher education and are certified as some flavor of APN.

As for treatment, RNs do not initiate treatment without a doctor's order. That said, for many things there are standing orders that it is the RNs job to understand and utilize in the course of caring for a patient.

Understanding disease, and therefore recognizing, is included as part of the nursing school curriculum. A good chunk of my med-surg lecture, as well as all of my pathophys lectures this quarter and in the fall, are devoted to understanding and recognizing disease. However, a lot of it is reinforced by practice, especially catching zebras. This is one of many reasons why nursing students have to do careplans - not just so that they get used to the mindset of how nursing care is organized and delivered, but also so that they look up and understand what's actually going on with their patients.

As for nursing theory, it's a subject geared towards defining and integrating what nurses actually do. While some of it, esp. things like Pender's model, are heavily grounded in reality, some nursing theories are, in either substance or application, a pile of New Age ********. My program went over that in one lecture session in the first quarter, and the only reason I'll be seeing it again is because I'll be doing a master's thesis next year.

I think that covers most of your post. If it doesn't, I'm sure someone else'll chime in.

AragornSkywalker · May 12, 2009

Little off topic, but can someone please explain this whole zebra vs horses idiom to me?

Deep C · May 12, 2009

If you hear hoofbeats in the distance, is it more likely to be a horse or a zebra? But the student (in real life often) makes the diagnosis of, say, a rare tropical disease rather than the common cold in the presence of sniffles, sore throat, and malaise. Perhaps the student correctly identifies one miniscule aspect of this rare disease (for example a hard to find neurological symptom) that does not exist in the common cold.

More often, students will overlook the obvious (common cold) in the quest for the unusual (rare tropical disease.)

You might read Samuel Shem's "The House of God" for this and other medical truisms (for example the origin of the pejorative "Gomer", "turfing", and especially the "Rules of the House of God.")

cjcsoon2bnp, MSN, RN, NP · May 12, 2009

I'm going into my junior year of nursing school and one of the biggest things I've noticed/learned is that a lot of people going into nursing school don't have a clear idea of what nurses really do and so when it comes time for students to go to clinicals they are a little surprised about the role of nurses in health care. I've been lucky enough to work in a hospital and in home care as a CNA so I have been able to see first hand what nurses do and how they fit into the health care delivery system, so clinicals have come as less of a shock for me.

Another big thing that many new nursing students don't always understand is that nurses do not make medical diagnoses (pneumonia, diabetes, coronary artery disease etc.) but they can make nursing diagnoses (impaired gas exchange, impaired skin integrity, caregiver role strain etc.) Nursing diagnoses tend to be more of a holistic approach then medical diagnosis and a nurse's ability to correctly identify and take steps to implement a nursing diagnosis can prevent or lessen the likelihood of a more serious medical diagnosis. For example: if a nurse identifies that a patient has impaired skin integrity the nurse can take the proper steps to lessen the likelihood of the patient developing pressure ulcers.

That being said you will find nurses who are able to spot a C-Diff infection just by the smell of the bowel movement or know that a patient most likely has pneumonia by the sounds they hear during auscultation of the lungs but nurses do not make medical diagnoses. The nurse will consult with the provider (NP, PA or MD) about the findings of a particular test or groups of tests and the provider will make a diagnosis which the nurse will then implement the treatments. I think that any student who wants to be a nurse should work as a nurses aide or at least shadow a nurse in a specialty of interest before they go to nursing school (or even during nursing school) so they have a better idea of what they are getting into before they finish their program.

!Chris :specs:

ArkansasFan · May 12, 2009

Thanks guys. When I was a paramedic student I largely worked with RNs during my clinical rotations so that I could practice skills such as assess, inject, infuse, blah blah blah. I have since wondered if they learned that more on the job or in school since as you say "nursing diagnosis" and "care plan" isn't something that I ever observed. I understand that nurses can't practice medicine thereby they don't use the verbage that a practitioner would, i.e. make a medical diagnosis, however, I've wondered if nurses even learn enough in the academic setting to be able to do that. I've never seen impaired gas exchange on a nurse's notes or anything that generic. I haven't worked as a paramedic in quite a while nor have I wanted to so I don't know what nurses are doing these days, but I suspect it's the same they were doing four years ago. Regardless of what nurses do, should I decide to become one, I'd like to be able to assess someone, interpret labs, and know that "hey, that guy has peritonitis" or something along those lines. Make sense?

It probably goes without saying that should I elect to pursue nursing that I'm interested in advanced practice roles as an end product.

jjjoy, LPN · May 12, 2009

Honestly, some schools seem to spend more time and effort into cramming through the required curriculum for board certfication and weeding out students who don't perform well on NCLEX-style test questions than on making sure students have a solid, relevant knowledge base and are prepared to function as nurses upon graduation. In order to stay in business, schools must cover certain material (TONS of content, see the several thousand-page nursing textbooks out there) and not have too many grads fail boards.

Schools will rationalize the lack of "real-world" prep by saying that no one expects new grads to be able to "hit the ground running" and that learning to "think critically" is more important than having specific skills because your workplace will provide you with the skills training that you need while nursing school is the only place that will specifically hone critical thinking. When students express concern about their lack of practical skills, you often hear the familiar refrain "you could teach a monkey skills, we're training you to be NURSES."

Also, many nursing programs seem to overemphasize the psychosocial aspects of nursing care, reiterating therapeutic communication and patient education over and over again while only giving cursory coverage to the hundreds of physiological conditions one may come across. Schools will defend themselves by pointing out that the medical aspects WERE covered (1 page of a 1000 page text book and maybe 1 minute of lecture) and it's up to the student to review it more on their own if it's not sticking.

With your questions, OP, though I have to wonder if you don't have more experience with nursing education than you are letting on. If not, you're very perceptive in regard to some of the weaknesses of nursing education and are going into it with eyes wide open. Knowing that, though, you can select a program that is more likely to suit your learning goals. And if school isn't specifically teaching you what you want, you can use it a starting point for your own further investigation and development. If there are any local student extern programs where students can get additional hands-on experience on the floor, that would be ideal.

Bicster · May 12, 2009

but I seriously am not getting what nursing school is teaching. Thanks for any replies.

Everything I have really wanted to know, I am teaching myself, or at least trying to. Patho, pharm, physiology, etc. Its actually kind of disapointing what we go over.

It really pi##es me off when people say: well, you should have gone to med school. No, I think we should spend less time learning how to appropriately interact with an Eskimo (cultural sensitivity), or writing care plans (which we just take from care plan books), and spend more time learing why we are doing what we are doing (what effect does this anti-hypertensive have on the body?) Maybe Im wrong, maybe its just my school, I dont know.

End of rant.

ArkansasFan · May 13, 2009

Honestly, some schools seem to spend more time and effort into cramming through the required curriculum for board certfication and weeding out students who don't perform well on NCLEX-style test questions than on making sure students have a solid, relevant knowledge base and are prepared to function as nurses upon graduation. In order to stay in business, schools must cover certain material (TONS of content, see the several thousand-page nursing textbooks out there) and not have too many grads fail boards.
Schools will rationalize the lack of "real-world" prep by saying that no one expects new grads to be able to "hit the ground running" and that learning to "think critically" is more important than having specific skills because your workplace will provide you with the skills training that you need while nursing school is the only place that will specifically hone critical thinking. When students express concern about their lack of practical skills, you often hear the familiar refrain "you could teach a monkey skills, we're training you to be NURSES."
Also, many nursing programs seem to overemphasize the psychosocial aspects of nursing care, reiterating therapeutic communication and patient education over and over again while only giving cursory coverage to the hundreds of physiological conditions one may come across. Schools will defend themselves by pointing out that the medical aspects WERE covered (1 page of a 1000 page text book and maybe 1 minute of lecture) and it's up to the student to review it more on their own if it's not sticking.
With your questions, OP, though I have to wonder if you don't have more experience with nursing education than you are letting on. If not, you're very perceptive in regard to some of the weaknesses of nursing education and are going into it with eyes wide open. Knowing that, though, you can select a program that is more likely to suit your learning goals. And if school isn't specifically teaching you what you want, you can use it a starting point for your own further investigation and development. If there are any local student extern programs where students can get additional hands-on experience on the floor, that would be ideal.

You've hit the nail on the head with my concerns. I really am not that familiar with nursing education other than reading course description and curriculum outlines in college catalogs and online. That said, they're aren't that detailed with information, yet I keep seeing recurring themes involving "theory." I'm not concerned with the present theories in nursing as they will change within a decade most likely. Every other professions' major theories change.

I had a friend in college who was in pre-nursing (I suppose that's what you'd call it), and I asked him something about being able to diagnose something one day. His eyes got big, and very quickly replied with some degree of exasparation, "I'm not a doctor. Nurses don't do diagnoses!" I suppose he had already gotten a similar rash of crap from other guy friends who living in south Arkansas tend to exude some element of that redneck persona. I think replied "Well, you're not a nurse yet so go ahead and diagnose, buddy." lol. I'm a cynic.

When I was in medic school I was in the ER one day doing whatever it was we did there, and the opportunity came to inject some guy with something I've long since forgotten about. This guy who happened to be an RN/EMT-P instructed the female nurse to let me give the injection, and she got real pi$$y and declared that I (me) didn't know anything about the drug at hand and that I wouldn't understand it's actions, etc. :rolleyes: His reply was, "Well, let him read about it first. Who cares anyway? He's just practicing giving shots." The end result was me giving the IM without reading about it. lol

ArkansasFan · May 13, 2009

Everything I have really wanted to know, I am teaching myself, or at least trying to. Patho, pharm, physiology, etc. Its actually kind of disapointing what we go over.
It really pi##es me off when people say: well, you should have gone to med school. No, I think we should spend less time learning how to appropriately interact with an Eskimo (cultural sensitivity), or writing care plans (which we just take from care plan books), and spend more time learing why we are doing what we are doing (what effect does this anti-hypertensive have on the body?) Maybe Im wrong, maybe its just my school, I dont know.
End of rant.

So why didn't you go to med school, Focker?!

Seriously though, this is an accurate summation of what I'm seeing in all of the different nursing "information" that I've looked at. I want to learn about disease and injury and how to treat it and cure it - NOT how to give a good hug. If I wanted to do that I'd be a social worker which, if you knew me, totally doesn't fit with my personality.

I think I'm looking at RN school as a basis to get into advanced practice and "do medicine." I really would prefer to be a physician, but I've got a great job that I really like. Sadly, in order to even apply to medical school I'd just about have to quit work to go take some pointless prereq courses in o-chem and physics that I otherwise would never consider taking. I probably wouldn't like being a nurse.

cjcsoon2bnp, MSN, RN, NP · May 13, 2009

When I was in medic school I was in the ER one day doing whatever it was we did there, and the opportunity came to inject some guy with something I've long since forgotten about. This guy who happened to be an RN/EMT-P instructed the female nurse to let me give the injection, and she got real pi$$y and declared that I (me) didn't know anything about the drug at hand and that I wouldn't understand it's actions, etc. His reply was, "Well, let him read about it first. Who cares anyway? He's just practicing giving shots." The end result was me giving the IM without reading about it. lol

I'm sorry but I'm going to have to agree with the nurse. I wouldn't give a patient an aspirin if I wasn't clear about why I was giving it to the patient, how the drug works, some of the potential side effects and what I should look out for after giving the drug. What happened if that patient had a reaction to the drug you administered but you were unaware of the warning signs of the drug interaction? You could be risking your patient's life because you didn't take the time to do a little reading and prep work about the drug your giving the patient. I'm not saying you have to become an expert on the particular drug but knowing a little bit about the drug your going to give to a patient could prevent a mistake from being made and save the patient's life. While you and the paramedic you worked with apparently seemed unconcerned about these details the nurse was right to speak up. If you "just wanted to practice giving shots" then you should have drawn up some saline and practiced giving it in a rubber arm.

I want to learn about disease and injury and how to treat it and cure it - NOT how to give a good hug. If I wanted to do that I'd be a social worker which, if you knew me, totally doesn't fit with my personality.

What you learn about in nursing school is much more then just "how to give a good hug", while nurses aren't social workers they do require knowledge on therapeutic communication and understanding a patient's mental and emotional needs. Health care cannot be boiled down to memorizing lab values and what medications treat which diseases, its a lot more complex than that. I think you would benefit from sitting in on a few different nursing classes to get an better idea of what nursing school is really all about.

Regardless of what nurses do, should I decide to become one, I'd like to be able to assess someone, interpret labs, and know that "hey, that guy has peritonitis" or something along those lines. Make sense?

That's a medical diagnosis. If you want to assess a patient, interpret labs and make a medical diagnosis then you should become a physician. It sounds like that is what you really want to do so you should look into a way of accomplishing that dream.

I think I'm looking at RN school as a basis to get into advanced practice and "do medicine." I really would prefer to be a physician, but I've got a great job that I really like. Sadly, in order to even apply to medical school I'd just about have to quit work to go take some pointless prereq courses in o-chem and physics that I otherwise would never consider taking. I probably wouldn't like being a nurse.

If you want to become a physician then become a physician, don't go to school and become a nurse as a way to "do medicine". Nursing school is not some shortcut or way to side step the prereqs of med. school. I agree with some of the other users that nursing schools tend to put a lot of focus on the theoretical practice of nursing and not as much on the hands on practical aspects of nursing, which is an area that they need to improve upon, but you learn the theoretical so you can understand the practical. Knowing to start a patient on 2L of O2 if they have a spO2 level of under 90 is great but it doesn't mean jack diddly if you don't understand why your doing what your doing and the expected outcome of starting a patient on O2. I'm sure I will be heckled to death for that but its my honest opinion. You might not see "impaired gas exchange" in a nurse's note or in the patient's medical record as a nursing diagnosis but the nurse that is treating that patient in respiratory distress is definitely thinking about impaired gas exchange and its complications while their treating that patient. I'm not going to stand on a soapbox and say that theory is the "end-all-be-all" of nursing but its important. I agree that in nursing school the practical, hands on portion of nursing isn't covered thoroughly enough which forces many new grads to learn skills on the job that aren't covered in school but there is a place for therapeutic communication and theory in nursing. Just ask the cancer patient whose oncology nurse took a few minutes to sit down and talk with them about how they were feeling regarding their diagnosis and their goals for the future instead of just administering their chemotherapy and moving on to the next patient.

!Chris :specs:

ArkansasFan · May 13, 2009

I disagree with what you said about aspirin. When I referred to the injection I was just there to stick the guy. We had x number of procedures to accomplish. I believe it was tetorifice immunoglobulin, but I was going to leave soon after probably as I never stayed there more than a few hours at a time. Let the staff do their jobs and let the students learn and practice what they need to practice. There's no point to injecting saline into a rub arm as it doesn't really feel or work the same. Doing the real thing is best, and yeah the other guy was an RN and paramedic. He knew what she was saying, but he understood exactly why I was there since he had been there himself. I appreciate your responses. An alternative to nursing that I looked at was ineeded becoming a physician or a physician assistant to which there are many perks exceeding that of a physician. I just want to learn the msot possible and do the most possible. Until recently I didn't think I'd be able to go to medical school due to some workplace scheduling concerns, but I've found a window of opportunity so my interests in nursing are rapidly falling by the wayside. Thanks for your reply. Most helpful.