What overwhelms you the most? What did NS NOT prepare you for?

[BeenThereDoneThat74]

Hi new grads!! I am trying to gather some real life information to bring back to my clinical students. I don't want this to be a bashing thread about your instructors (because it's never OUR fault...ha ha ha ), but rather a reflective thing.

The reason I pose this question is this: My students (as many others before them) think that nursing school (and nursing thereafter) is all about skills!! If I had a dollar for every student that has complained that they have not inserted a foley, or are nervous about it, I'd be a millionaire!! Our graduating class did a survey (for a research project) and the most popular answer for "what skill do you feel most unprepared for as a new nurse" was that!! This beat 'taking care of a vent patient' :uhoh21:. Meanwhile my students (while very good this semester... 2nd semster) still at times could not give me a nursing diagnosis, tell me why patients were on a baby aspirin (pain?), where the MD orders are in the chart (or why we need to check MD orders to the MAR, not MAR to their cheat sheets) or other "non-tangible" skills.

I know skills are important. But as time goes on, you get these skills. I tell them a monkey can insert a foley and set up an IV. I also told them that I would never fail someone who did not perform a skill correctly (ie break sterility during a foley). Maybe it's just me, but the other things are more important, like how to assess, problem solve, prioritize, communicate, and most of all apply the theoretical knowledge into clinical practice. I tell them there is a reason they sit there in lecture.

So basically, I wanted to know: has anyone ever been thrown off orientation because they didn't remember how to perform a basic skill, or made a mistake with it? What gets you caught up as a new grad? And what can I tell my students (I have a feeling that nothing I say will help )?

[SoundofMusic]

Two words: Charting and paperwork.

If anyone had shown me what nurses are responsible for in these two arenas, I think I would have fun away right then and there.

I can relate to patients. i can critically think. I give great report even -- but paperwork is such a bear. I just can't believe the atmosphere of CYA at all times. It's just demoralizing sometimes to think i have to live in constant fear of my backside not being "covered" at all times.

[jAy-FibRN]

I am a recent grad and I will be off orientation in 2 weeks and starting nights (630pm-730pm) on a Med/Surg-Tele floor with 4 pediatric beds. I will be taking on 8-10 patients religiously. This overwhelms me a great deal. Does anyone have any advice for this overwhelmed male nurse?? Is taking 8-10 patients, most of the time 10, safe for a new grad? This doesnt really go along with the thread but I see some very experienced nurses here and would value their advice tremendously!!

[jjjoy, LPN]

What's the solution to this? The one that I know my students don't want to hear: practice in the lab!! We know repetition of a task reinforces your ability

Our skills lab was only available during our scheduled lab classes. Any other practice had to be on our own with whatever supplies we could reuse for practice, without any feedback about whether the technique we were practicing was good or not.

And then there's text-book correctness of a skill (that we were tested on) and real-world competency of a skill. Being able to place a foley in an exact, robotic process of 30 distinct steps will only go so far in helping the student achieve the kind of proprioceptic (?) learning (being able to do something without thinking - like a tying a shoe) that will lead to clinical confidence and competence.

[CABG patch kid, BSN, RN]

New grad here, 3 weeks off orientation. The hardest thing for me right now is seeing the big picture. I feel like my night is filled with so many tasks; vitals, assessments, check orders, med pass, rinse, repeat. I feel like I don't have a whole lot of time to sit around and think about the patho of my patient's disease processes, especially when most of them have co-morbities and this processes can work together in interesting ways ( pt. with CHF and renal failure; what's causing that edema? did the CHF cause the RF? things like that boggle my mind). I have good enough assessment skills to know when something is WRONG, but when I go get second opinions from the more experienced nurses, they start asking me a ton of questions about the patient that I feel I should have thought of on my own. And the reason why they are asking these particular questions makes sense to me, I know why they are asking me about the electrolytes, CBC, etc etc, I just wish I could think of it on my own. Sometimes I do, I'm getting better, I'm hoping that this is the critical thinking stuff that just comes with time.

I don't even know if that helps answer the original question!

[jjjoy, LPN]

New grad here, 3 weeks off orientation. The hardest thing for me right now is seeing the big picture. I feel like my night is filled with so many tasks; vitals, assessments, check orders, med pass, rinse, repeat. I feel like I don't have a whole lot of time to sit around and think about the patho of my patient's disease processes, especially when most of them have co-morbities and this processes can work together in interesting ways ( pt. with CHF and renal failure; what's causing that edema? did the CHF cause the RF? things like that boggle my mind). I have good enough assessment skills to know when something is WRONG, but when I go get second opinions from the more experienced nurses, they start asking me a ton of questions about the patient that I feel I should have thought of on my own. And the reason why they are asking these particular questions makes sense to me, I know why they are asking me about the electrolytes, CBC, etc etc, I just wish I could think of it on my own. Sometimes I do, I'm getting better, I'm hoping that this is the critical thinking stuff that just comes with time.

Given how busy nurses are, there really ISN'T much opportunity to figure out the "big picture" for every patient that you care for. You manage from day to day, patient to patients and learn as you go. After awhile, you will start seeing the same types of things and it will be more familiar. One bit of info will 'click' one day. Another bit might click a few weeks later.

I think schools tend to go a bit overboard in emphasizing the need to see the big picture, perhaps overcompensating for the too common assumption that nurses don't have to understand anything, they just *do* whatever is orders. It IS important to grasp the "big picture" but like all of nursing, you have to prioritize. Keeping a patient from falling comes before flipping through a patient's chart to get a better grasp of their entire hospital course. Identifying that something IS wrong with a patient comes before understanding the relationship of the electrolytes, CBC, and the patient's symptoms.

Unfortunately, it often comes across that if you've been told once, you should *know* it and remember it for all time to come. And that's just not realistic. Each time the experienced nurses ask you those questions, instead of thinking of it like "I should already know this!" think of it more like "Five more times and THEN I'll remember this!"

[*ac*]

Nursing school did not adequately prepare me with skills. I know what many are saying: that skills can be learned by a monkey, but how can I critically think when I'm struggling so much with basic skills? If hospitals could give you many weeks of just skills training, without expecting you to think and prioritize, etc, then fine, don't worry about it in school. But they expect you to have it all pretty much under control within 8-12 weeks.

Nursing school did not prepare me to hold the needs of 5 patients in my head at one time. I don't know how this could be done in school, but one patient and a couple of meds is not even close to adequate prep.

Nursing school did not prepare me for mean, unsupportive, backstabbing nurses.

Nursing school did not prepare me for the fact that if you're in the room or assigned to the patient when there's any kind of a problem, and you have an RN after your name, than it's your fault.

I have not finished orientation and I may be done with hospital nursing.

[jjjoy, LPN]

If hospitals could give you many weeks of just skills training, without expecting you to think and prioritize, etc, then fine, don't worry about it in school. But they expect you to have it all pretty much under control within 8-12 weeks.

Well-put!

Nursing school did not prepare me to hold the needs of 5 patients in my head at one time. I don't know how this could be done in school, but one patient and a couple of meds is not even close to adequate prep.

So true!

[SoundofMusic]

Yeah. It's like you go to nursing schooland pass a few tests.

Then you start the "real" job, which is sort of like starting another school all over again.

Only it's with real live people, co-workers, doctors, and everyone else in between.

[CABG patch kid, BSN, RN]

Unfortunately, it often comes across that if you've been told once, you should *know* it and remember it for all time to come. And that's just not realistic. Each time the experienced nurses ask you those questions, instead of thinking of it like "I should already know this!" think of it more like "Five more times and THEN I'll remember this!"

Thank you, I needed to hear that!

[NightshiftRN69]

The thing that I feel I was less prepared for was

How to choose between the patient who needs me to hold their hand or tell them someone cares and then show that you do or how to find the time to sit with the patient after they tell you "just let me die" or "I'm not faking my pain or illness" or how to clean up a 350 lb patient who was just admitted from an OSH in deplorable condition by yourself and still get all of your patients cared for, give your patients their pain meds when your co-workers come and tell you the need it and all of your paper work completed fully not any mistakes and clock out on time.

[imanedrn]

New grad here, 3 weeks off orientation. The hardest thing for me right now is seeing the big picture. I feel like my night is filled with so many tasks; vitals, assessments, check orders, med pass, rinse, repeat. I feel like I don't have a whole lot of time to sit around and think about the patho of my patient's disease processes, especially when most of them have co-morbities and this processes can work together in interesting ways ( pt. with CHF and renal failure; what's causing that edema? did the CHF cause the RF? things like that boggle my mind). I have good enough assessment skills to know when something is WRONG, but when I go get second opinions from the more experienced nurses, they start asking me a ton of questions about the patient that I feel I should have thought of on my own. And the reason why they are asking these particular questions makes sense to me, I know why they are asking me about the electrolytes, CBC, etc etc, I just wish I could think of it on my own. Sometimes I do, I'm getting better, I'm hoping that this is the critical thinking stuff that just comes with time.

I don't even know if that helps answer the original question!

This is a good point because it is a definite reality for new grads. I'm still in this boat, and I precepted for 8 weeks and have been on my own for 8 weeks now.

The big picture is incredibly difficult to see when you're worried about all the tasks, rinse, repeat. (Great analogy, by the way!) The good thing, though, is that, as those "repetitions" become more natural, you are able to look at the big picture. Once charting and passing meds becomes more "routine" (while still maintainingg safety and the 5 rights!), you're more able to look at that big picture and ask "why is this patient on X med and why did I hear X type of lung sounds, hypo bowel sounds, edema in X extremity, etc.

It's good that you're aware of this, though, because it can be SO overwhelming for SO many new grads -- as it was for me!

In any case, be hopeful that, just as you progressed in nursing school, you will progress in the real world. Also, remember: You always get out what you put into it!

[Morettia2, BSN, RN]

Ok I am 9 months into my frist year of nursing on a VERY high paced cardiac floor, Interventional Cardiology/CCU step down. I choose cardiac b/c I had 3 semesters of tele in NS, I was the only studet at my school that had 3 semesters tele exp. at 3 different hosp. My NS gave me great experience at a ton of different hosp.'s, and settings. But there are a few things that I wish to god I would have learned in School. Giving report at change of shift,at my hosp. we give verbal nurse to nurse reports, I work 7p-7:30a. I HATE REPORT, I have been doing it for 9 months and it still takes forever to give report, and I am not the only NOC nurse that has this problem, all the NOC nurses are there till at least 8:30am or later giving report. I have had multiple report sheets that I have used and the only one that works is the one that I have made myself that some of the other NOC nurses use. The other thing is my NS, like so many Nursing Schools in PA, don't allow student nurses to start IV's or do blood draws. The hosp. I work at in NJ gave us classes when I started as a new RN. Yea, I can draw your blood and get a vein from any part of your arm, BUT I SUCK at inserting an IV, I mean I am AWFUL AT IT I am certified but AWFUL. But if you need STAT labs I am you girl.The other thing that NS didn;t prepare me for was MD interaction. The MD's I get along with, but it's is the matter of which MD to call, there are conflicting orders written by different MD assigned to the pt. Most cardiac pt's have b/t 2-6 MD's assigned to them. I call both MD's that wrote the orders, they can't agree, so I call the attending and get the final order..it kills me all the time. Since I work nights makes it worse, housse MD, tele resident, cardiac fellow, do I wake this MD up at 3:50AM b/c no one covers them. I have learned ALOT about MD interaction. I think that Nursing Schools should spend a class in the last semester of Nursing school about MD interaction, and Night Shift Nursing. I never once in School learned anything about Night Shift Nursing.I DEF. think Nursing schools should spend a clinical lab on shift report. Each student nurse should have to give an instructor a verbal report on a mock pt (done in the Sim Lab), stating recent procedures, any labs that were done for that day or pending labs, dietary status, IV Drips, PMH, the MD's assigned to the to the Pt. and the speciality of each MD, if the pt. is AC/HS FS, any Daily Wt.'s, I&O's, any upcomming procedures, pending tests, what the PLAN is for that pt.(discharge, rehab, nursing home, home care ect..)...we did care maps in NS, I do them NOW as an RN daily but it still dosen't help, and I am not the only RN on my floor with this problem. I took report from my clinical instructor, or the nurse in the morning while in School. But I RECIEVED report, as a student, never gave report b/c we were only on the floors, as students for 6-8 hours, we never had to give report to the RN's. I Def.think a Sim lab in NS on giving report at change of shift would have helped ALOT.