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

Nurses New Nurse

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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?:banghead:), 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 :no:)?

Specializes in ED/trauma.
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.

What causes the night nurses to get out so late? Are the day nurses asking too many questions / expecting too much of your shift? I work days and report lasts anywhere from 20-45 mins depending on how much has gone on that days (a couple orders vs. 20) and the nurse to whom you're giving report (some want the basics and will find the rest out for themselves, whereas others want every bloody detail).

As for report, during my final semester, we had 12 precepting shifts where we did the full 12 hr shift with our preceptor. Once the preceptor was comfortable with us, they would encourage (some more than others) to give report and maybe fill in the details we missed. This was a great learning opportunity because, I agree, report is tough! Even while I was precepting as a NG I found it difficult, mostly because it's frustrating (a) to adapt your personal reporting style to the several other styles that nurses have and (b) my preceptor would do so much for me and NOT tell me about it UNTIL report, so I often felt like a donkey's rear...

Nursing school, by far and away, will NEVER be enough preparation for the real world of nursing. I'm convinced it's just simply not possible. If you're lucky, though, you'll work with some understanding people who are willing to help ease you through the transition process. While I've met a few rotten apples (those nurses that are just plain mean!), most are very helpful. I even have one who HATED reporting off/on with me, who I get along with great now.

There is a light at the end of the tunnel, though!

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Specializes in Ortho, Case Management, blabla.

This one time I had a patient coding, and one of the nurses that came to the code said, "We need a stomach tube!!" So I went to the supply room and found something labeled "stomach tube." Brought it back...She said, "NO I MEANT AN NG TUBE!!!" I went back and could NOT find an NG tube. I was frantically searching for the dumb thing for like 5 minutes. Finally that same nurse came in as I was turning over like every stone in the supply room. I said, "I think we're all out of NGs I'll run to central supply!" And she said,"Its RIGHT THERE" grabbed it and ran out. Duh....NGs were labeled as Salem-Somethings ...I just needed to step back, take a deep breath and think for minute.

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Specializes in Travel Nursing, ICU, tele, etc.

I am an old time nurse starting in a new environment and even as a nurse with 10 years experience, it sucks being new. Some people are just plain mean to you when you are new. They don't care how much experience you have, they reportedly at this institution put you through a "hazing" period or as another nurse called it, "tough love". Well, I call it bull crap. The biggest thing I would tell a new grad is to develop that thick skin asap and find those few coworkers who will actually treat you well and stick to them as much as you can. As a new grad, you will be especially vulnerable and will want to get some approval for how you are doing. I recall that it was VERY strange that I wasn't hearing anything from anybody for how I was doing and what I have found in nursing is this: no news is good news. You probably will not get the positive feedback that you will want, but just know that you will definitely hear about things you do wrong, so if you hear nothing, that is a good thing!!:mad::mad::mad:

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Specializes in Emergency.

I am a new grad working in the ED :D and while I was nervous about the skills I hadn't had much practice with, I got plenty of time to practice with my preceptor and if something comes up that I have never done before, my co-workers are ALWAYS there to help. I am now after 4 months finding that I wish my nursing clinicals had focused less on the paperwork and more on the patient care. I go home everyday and reflect on my day, what did I do right, what do i feel good about, and what do I feel like I could have done better. I find the times that I feel like I could have done better are when I get overwhelmed with heavy patients or have to watch over my partners patients in addition to mine while they transport a patient to ICU or CT or MRI. ( I always ask for help and never forget about patient safety)

After the first few semesters the paperwork got very repetitive and it felt like we were jumping through hoops with more emphasis on APA formatting than actual content. I actually had a clinical instructor tell me he didn't read my careplans anymore because he knew they would be perfect. I wish my clinical instructors would have pushed us out of our comfort zones to take on more patients as they felt we were safe to do so. I have gotten great feedback from my charge nurses and patients, but had I not done a preceptorship in the ED in my last semester of nursing school I don't think I would have been able to do it.

For example, we would do our pre-planning the day before clinicals, writing 30+ page care plans with pathophysiology of each co-morbidity down to the cellular level, nursing diagnoses with interventions and rationales, serial labs and descriptions of the abnormal values, med tables with action, rationale, side effects, contraindications, interventions and administration guidelines, and different variations depending on the area (med-surg, critical care, peds, etc). We would generally take 2 patients, except in critical care where we took only one patient (and had longer care plans). These care plans took about 16 hours to complete. This all helped immensely to put together the big picture and see how all the comorbidities affected the patient and their treatment, and for me being in the ED, how to assess patients, what questions to ask, etc. NOW FOR MY POINT :bugeyes: If we came in on the day of our clinical and were not able to take the patient for some reason (discharged, too many students with one nurse, etc) we would have to choose a new patient and write another care plan instead of caring for the patient. I see the point to the paperwork, but in our limited clinical time I do not see the benefit in doing more paperwork instead of getting the experience you cannot get from books.

I know it takes time and I don't think that nursing school has to get us completely ready, but something my mother told me sticks with me. She was a nurse for 37 years and went to a hospital run school where she worked for the hospital during school. She noticed that as nursing schools moved from the hospitals to the classroom that new grads were less and less prepared for actual nursing. I feel like we needed more clinical time. (I was in a BSN program if you need to know)

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I am almost finished my second year...these are my only skills that I have actually PRACTICED.

bedpans

bath

changing linens

vitals

2 shots

That's it.

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Specializes in Ortho, Case Management, blabla.
I am almost finished my second year...these are my only skills that I have actually PRACTICED.

bedpans

bath

changing linens

vitals

2 shots

That's it.

don't worry, you'll have TONS of time to practice everything else from the point that you graduate until you retire. seriously.

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don't worry, you'll have TONS of time to practice everything else from the point that you graduate until you retire. seriously.

Very true, but what's the point of a student training period if it isn't to train in what you'll actually be doing for 80% of your working day?

And in regard to those long detailed care plans, they ARE a great learning tool for see how different systems and pathologies and medications interact. However, most nurses work in real-time and deal with what's going on NOW. So while students should get some practice in putting all the pieces together, I think students ALSO need to practice and learn how to deal with what's right before them.

In the "real world" they won't know what their patients' diagnoses and status' will be before they receive shift report, nor have several hours to look up the pathophys, treatments, etc. And there's no realistic way for students to get the chance to do a comprehensive care plan on every possible type of patient they are likely to come across after graduation. Many schools don't teach students how to function WITHOUT such extensive pre-planning or without knowing a patient's full history and course of illness to present.

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Specializes in CTICU, Interventional Cardiology, CCU.
What causes the night nurses to get out so late? Are the day nurses asking too many questions / expecting too much of your shift? I work days and report lasts anywhere from 20-45 mins depending on how much has gone on that days (a couple orders vs. 20) and the nurse to whom you're giving report (some want the basics and will find the rest out for themselves, whereas others want every bloody detail).

As for report, during my final semester, we had 12 precepting shifts where we did the full 12 hr shift with our preceptor. Once the preceptor was comfortable with us, they would encourage (some more than others) to give report and maybe fill in the details we missed. This was a great learning opportunity because, I agree, report is tough! Even while I was precepting as a NG I found it difficult, mostly because it's frustrating (a) to adapt your personal reporting style to the several other styles that nurses have and (b) my preceptor would do so much for me and NOT tell me about it UNTIL report, so I often felt like a donkey's rear...

Nursing school, by far and away, will NEVER be enough preparation for the real world of nursing. I'm convinced it's just simply not possible. If you're lucky, though, you'll work with some understanding people who are willing to help ease you through the transition process. While I've met a few rotten apples (those nurses that are just plain mean!), most are very helpful. I even have one who HATED reporting off/on with me, who I get along with great now.

There is a light at the end of the tunnel, though!

Day shift gives the worst report at the hosp. I work at. I ask the relvant questions but we NOC shift always end up with the worst report. And yes most of the nurses in the morning are asking questions that takes a blink of an eye to look up. It drives me nust to no end sometimes when I am there for an hour and a half post shift giving report and falling alseep driving home and some even have the nerve tpo call me at home and ask me like 1000 more questions ..one day I say well I do this at night LOOK IN THE CHART and don't boehter me unless it's life or death and don;t call and ask me what the NS is set at look at the doctors orders and I wrote it in the care plan in the bedside..open you eyes..no offense to day shift it's only like this at my hosp..

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Specializes in ED/trauma.
Day shift gives the worst report at the hosp. I work at. I ask the relvant questions but we NOC shift always end up with the worst report. And yes most of the nurses in the morning are asking questions that takes a blink of an eye to look up. It drives me nust to no end sometimes when I am there for an hour and a half post shift giving report and falling alseep driving home and some even have the nerve tpo call me at home and ask me like 1000 more questions ..one day I say well I do this at night LOOK IN THE CHART and don't boehter me unless it's life or death and don;t call and ask me what the NS is set at look at the doctors orders and I wrote it in the care plan in the bedside..open you eyes..no offense to day shift it's only like this at my hosp..

That's does sound pretty insane -- esp. to be called at home for the rate of NS! Wha??? Is there some intervention that mgmt or charges can take in these situations? It just sounds... weird.

As I said, I've had to adapt to different nurses' reporting style / some days being more difficult than others, but if you're dealing with this on a regular basis, then it sounds like a problem that needs some fixing.

Good luck!

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Specializes in Pediatrics.
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.

And there you go!! You just saw the big picture, and prioritized!!!

As my old boss used to say, there's a method to our madness!! In order to prioritize, you need to grasp the 'big picture'. How can you decide who is your priority until you have given everyone a quick once-over? How can you decide who needs to be seen first, who can wait, etc?

Yes, the falling patient DOES come before flipping through the chart. I NEVER condone flipping through a chart to get the full history before checking patients (but that's just me). I have students sitting at the station knee-deep in the chart, and haven't even checked to see if the patient is there, let alone alive. I will ask them if they need to know all that info before walking in, assessing and taking VS? As an RN, you do not have time for that. You rely on a good report to get the quick version of the pertinent history. As a student, this is where the primary RN comes in...ask for a quick report. I know all nurses are not receptive to students, but if you show the initiative and ask for infor, most of them will oblige.

It takes time, no one expects you to grasp this overnight (or at least no one should). If they do, they really needed to be reminded thay they too were once a new grad, in the exact position you were in. If someoen does not like your style of report, ask them "what am I leaving out? Am I giving you too much unimportant info?".

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Specializes in Pediatrics.

For example, we would do our pre-planning the day before clinicals, writing 30+ page care plans with pathophysiology of each co-morbidity down to the cellular level, nursing diagnoses with interventions and rationales, serial labs and descriptions of the abnormal values, med tables with action, rationale, side effects, contraindications, interventions and administration guidelines, and different variations depending on the area (med-surg, critical care, peds, etc). We would generally take 2 patients, except in critical care where we took only one patient (and had longer care plans). These care plans took about 16 hours to complete. This all helped immensely to put together the big picture and see how all the comorbidities affected the patient and their treatment, and for me being in the ED, how to assess patients, what questions to ask, etc.

OMG!! I NEVER heard a student say this!! :bowingpur I'm sooo glad you saw the point. I did see your point beyond that as well (if you didn't have the patient). Sadly, there is nothing we can do about that :uhoh21:

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Specializes in Pediatrics.
I am almost finished my second year...these are my only skills that I have actually PRACTICED.

bedpans

bath

changing linens

vitals

2 shots

That's it.

Here is my EXACT point of this thread.

So tell me, what did you do for two years, since you did NOT do all the skills? Please tell me you learned something. Do you know how to assess, chart, I&0, teach, discharge, wound care, caring for more than one patient? Please tell me you did something else:uhoh3:

The only thing that really concerns me that I do not see on your list is IV meds. Did the rest of your class do more than this? If they did, then you should have spoken up to your CI and told him/her that you needed to do some of the things not on this list. Although I try to keep a list, it is very difficult to keep track of who has done what, so I ask my students every couple of weeks, 'who still needs an NG, IVPB,?'. Because even by the time you get to second year clinical, your CI will not want to hear that you never did an IV.

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