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 )?

[SunnyAndrsn]

I just finished my third semester, will be starting my last two theory classes next week. I took my LPN boards and am working in a LTC facility right now.

My first week I was so overwhelmed, I came home and told dh "I'd like to say don't they know I just graduated but I'm afraid they'll fire me!"

Three months into all of this, I'm feeling better, somewhat more proficient but still unsure. Things NS did not prepare me for?

-Supervising CNA's--not just delegating, but managing squabbles, CNA "breaks" aka smoke breaks, coming in late, leaving without checking with the nurse, etc.

-Managing my own time

-Realizing that I would need to depend on my aides to keep me informed, as it's impossible to do a head to toe and/or skin assessment on 24 residents each shift--and learning when it was critical to do those assessments.

-Good nursing does NOT equal doing it all myself--see above, but I AM responsible for each of my residents care.

-Legal aspects of nursing care, specifically Medicare charting

-paperwork, yes I know each facility is different, but experience taking a dr's order, writing that order, and updating all the associated paperwork--the MAR, the charting, pharmacy calls.

-how to make each moment I am with my residents count--when I go into a room, what do I see? What's important about my residen'ts condition to see in the few minutes it takes me to give them their medications.

-How to take a good shift change report, and how to give one in turn. Also, how to update/give the CNA's report as well.

Above all, nursing school didn't prepare me for how much I'd learn to love my residents and how much I'd worry when I leave each night. Also, how glad I'd be to leave each night--and how guilty I'd feel at first.

Because of the nature of nursing school, I learned to ignore my needs. And let's face it, women are pretty darn good at ignoring their own needs anyway. Nursing school failed to prepare me for how important it is to build my personal coping mechanisms for dealing with an extremely stressful job.

[Furwillfly]

Sunnyandrsn:

Said it very well! Great read! I've been at the same LTC facility for 5 years now and I still have all those worries on your list. It gets better, but they are still there almost everyday. I try to 'empower' my CNA's by teaching them stuff they don't know about assessment skills, and I do nice things for them when they earn it; it is unbelievable how much more they come tell me stuff! They are my backbone, I couldn't do it by myself. Anyhow, thanx for sharing your words.

[Kiringat]

My

I graduated on Saturday. I am scared to start practicing. I feel like my school has prepared me to take the NCLEX - not take care of patients. I can think critically, list and describe SE and actions for meds, prioritize patients on paper, go through the pathophysiology of a dx, and describe all possible aspects of procedures.

However, I don't know if I can recognize symptoms of a dx in a real breathing patient, much less prioritize them. I don't know how to delegate and supervise UAP. I'm not sure how to give report or talk to a MD. And sure, I can tell you how to drop and NG, but as for actually doing one...

I just don't know. I've been through and learned so much over the past two years, but its not enough. I feel like I've learned all this theoretical perfect world stuff, but have no experience in applying it to the real world. I can't believe that I'm going to be "the nurse" now, I'm just not ready for it. But it kinda helps to know I'm not the only one who feels that way!

[BeenThereDoneThat74, MSN, RN]

If you read the new grad forums here long enough, you will see the level of anxiety of new grads, much of it related to their lack of skills and experience with patients. Many hospitals experience retention problems with their new grads. WAKE UP, EDUCATORS!

Wow, I didn't know I was asleep .

You lumped 'lack of skills' and 'experience with the patients' in the same category. While I am certainly not minimizong the need to know the skills, the 'experience with the patient' is one of the things I am referring to. The assessments, and the 'what's going on here' apsect of it. I do get that it has to be a mix of all these things, theory and practice.

I do appreciate your input, and hope that you can see where I am coming from, having been teaching for three years already. I knpow it is not a long time, but I too felt like you did when I started doing this, that it is all about the skills.

I feel like my school has prepared me to take the NCLEX - not take care of patients. I can think critically, list and describe SE and actions for meds, prioritize patients on paper, go through the pathophysiology of a dx, and describe all possible aspects of procedures.

It seems to me that a good number of my students are just so focused on NCLEX (and all tests leading to that) that they lose sight of why they are in school. Example, I recently taught 3.5 hours of content, and my class was so disappointed to see that I only had 8 test questions on the topic (not my choice, i am told how many questions I was alloted). Their rationale? How can I narrow it down. how can I figure out what your 8 questions will be? Not sure if I am explaining it right, but it seemed to me that they were only focused on the test, not knowing and understanding the material, just figuring out what I could possible ask them.

However, I don't know if I can recognize symptoms of a dx in a real breathing patient, much less prioritize them. I don't know how to delegate and supervise UAP. I'm not sure how to give report or talk to a MD. And sure, I can tell you how to drop and NG, but as for actually doing one...

I totally see your point. And apparently others here agree with this, the things that are not so cut-and-dry, like delegating, giving report, etc. These are not concrete tasks that can be memorized, but rather concepts.

The reality is, there is NOT enough time to be taught everything you need to while in nursing school.

[oldiebutgoodie, RN]

I do appreciate your input, and hope that you can see where I am coming from, having been teaching for three years already. I knpow it is not a long time, but I too felt like you did when I started doing this, that it is all about the skills.

Hi, nurse educate,

I don't want anyone mislead--you quoted my post as well as a new grad's post in the same posting. The first two quotes were mine, the second two quotes were from Kiringcat.

And I did not say that it is all about the skills. I did say that there is not enough (hardly any) training in skills, and that there is a theoretical basis to this, based on Benner, Bandura, and Maslow.

Regards,

Oldiebutgoodie

[jjjoy, LPN]

Wow, I didn't know I was asleep .

I don't think that was directed to individual educators but to nursing education in general. Many instructors (I'm not saying you do this) blithely assure their students that they don't need to master x,y,z in school because hospitals will provide them with on-the-job training. Many hospitals (and nursing colleagues), on the other hand, don't seem satisfied with the abilities of new graduate nurses and aren't so gung ho on having to provide extended preceptorships to new grads.

Example, I recently taught 3.5 hours of content, and my class was so disappointed to see that I only had 8 test questions on the topic (not my choice, i am told how many questions I was alloted). Their rationale? How can I narrow it down. how can I figure out what your 8 questions will be? Not sure if I am explaining it right, but it seemed to me that they were only focused on the test, not knowing and understanding the material, just figuring out what I could possible ask them.

While I definitely see your point that students should be concerned with learning as much as they can whether or not they are tested on it, it does seem a bit strange that you're only allotted 8 measely questions to test students on 3.5 hrs of content. It's not a criticism against you, but against nursing education in general. Why doesn't nursing education TEST students on "knowing and understanding the material" instead of just 8 random points out of 3.5 hours of content? Why are instructors limited to such an extent in their ability to test students? I'm sure it's to "prepare students for the NCLEX"... but that doesn't prepare students to be nurses. That kind of limited testing only encourages the kind of 'bare minimum' studying that you rightly criticize.

The reality is, there is NOT enough time to be taught everything you need to while in nursing school.

So true. So what is the MINIMUM that *should* be taught? I find it a challenging question myself without an easy answer.

[nursemike, ASN, RN]

Wow, I didn't know I was asleep .

You lumped 'lack of skills' and 'experience with the patients' in the same category. While I am certainly not minimizong the need to know the skills, the 'experience with the patient' is one of the things I am referring to. The assessments, and the 'what's going on here' apsect of it. I do get that it has to be a mix of all these things, theory and practice.

I do appreciate your input, and hope that you can see where I am coming from, having been teaching for three years already. I knpow it is not a long time, but I too felt like you did when I started doing this, that it is all about the skills.

It seems to me that a good number of my students are just so focused on NCLEX (and all tests leading to that) that they lose sight of why they are in school. Example, I recently taught 3.5 hours of content, and my class was so disappointed to see that I only had 8 test questions on the topic (not my choice, i am told how many questions I was alloted). Their rationale? How can I narrow it down. how can I figure out what your 8 questions will be? Not sure if I am explaining it right, but it seemed to me that they were only focused on the test, not knowing and understanding the material, just figuring out what I could possible ask them.

I totally see your point. And apparently others here agree with this, the things that are not so cut-and-dry, like delegating, giving report, etc. These are not concrete tasks that can be memorized, but rather concepts.

The reality is, there is NOT enough time to be taught everything you need to while in nursing school.

One of my NS clinical instructors used to get on us a bit because it didn't seem like we were "having fun" in clinicals. Was she out of her flippin' mind?

Funny thing is, along about my second or third week of orientation, it finally dawned on me that, hey, I was having fun! Granted, it's just about the hairiest rollercoaster ride around, but being a nurse is a blast, when you aren't peeing yourself.

I guess it's true--you just can't learn everything in nursing school.

[BeenThereDoneThat74, MSN, RN]

I don't think that was directed to individual educators but to nursing education in general. Many instructors (I'm not saying you do this) blithely assure their students that they don't need to master x,y,z in school because hospitals will provide them with on-the-job training. Many hospitals (and nursing colleagues), on the other hand, don't seem satisfied with the abilities of new graduate nurses and aren't so gung ho on having to provide extended preceptorships to new grads.

I know there is a huge communication gap between my world (the academia world) and the staff education world. one of my colleagues recently came from a career in staff ed, and, as she put it, it all makes sense now, as to why the students come to them knowing as little as they do. She said she would curse us under her breath, wondering what exactly went on in nursing school. She now realizes how contranied the nursing programs are. I truly beleive until you walk a mile on the other side of the fence, you can't make judgments.

While I definitely see your point that students should be concerned with learning as much as they can whether or not they are tested on it, it does seem a bit strange that you're only allotted 8 measely questions to test students on 3.5 hrs of content. It's not a criticism against you, but against nursing education in general. Why doesn't nursing education TEST students on "knowing and understanding the material" instead of just 8 random points out of 3.5 hours of content? Why are instructors limited to such an extent in their ability to test students? I'm sure it's to "prepare students for the NCLEX"... but that doesn't prepare students to be nurses. That kind of limited testing only encourages the kind of 'bare minimum' studying that you rightly criticize.

Do you know how long the exams would be if we had carte blanche?? My students would hate me even more!!!

So true. So what is the MINIMUM that *should* be taught? I find it a challenging question myself without an easy answer.

That is the million dollar question

[BeenThereDoneThat74, MSN, RN]

And I did not say that it is all about the skills. I did say that there is not enough (hardly any) training in skills, and that there is a theoretical basis to this, based on Benner, Bandura, and Maslow.

I get the theoretical basis of all that. But again, it boils down to time. There aren't enough hours in the day/week/semester for it. Back in the days of diploma programs, students did much more clinical time, but in a 3 year program. And with class sizes and clinical groups being filled to capacity, there is no way that the time can be devoted during regular class/lab/hours. I wish we could, because then clinical time could be spent more on actual patient care, assessments, and all the other stuff our new grads are also not prepared for. So much of the clinical day is spent on reviewing techniques and steps in the skills.

[jjjoy, LPN]

Warning - off topic - please feel free to continue on the discussion answering the original questions: what overwhelms you most? What did NS NOT prepare you for?

Nurse educate (or anyone else interested) What are your thoughts on the idea of a standard nurse "intern" period that is done after completing a mostly didactic (sp?) program of study? Say something like an accelerated one year/1.5 yr RN program covering common diseases, pathophys, symptom management, and of course, nursing care and care planning. (For time's sake, specialty areas such as maternity, ICU, OR might be left for further optional study later as a specialty). Toss in skills lab coverage of a range of nursing skills - but less actual patient care/clinical time than currently required - mostly to ensure that students are safe to administer medications and have adequate assessment skills.

Once this section is passed, students receive their RN license. This license, by itself, though, wouldn't qualify them to work in any RN role. They would have to complete a clinical internship before being qualified for acute care RN jobs With the license, they could be qualifed to apply for full-time internships where they work one-on-one with preceptor nurses on a 2/3 schedule with 1/3 education component. There might be other available internships that could focus on specialty areas not covered in the basic training, or perhaps specifically on LTC or community health.

In the acute care setting, maybe interns spend at least 8 weeks on at least 4 different units for a time period of, say, six months. As interns, they legally could NOT be counted in RN-to-patient ratios. However, with their own license (based on having passed a rigorous year of study), they wouldn't be such a burden on staff as nursing students are. Once interns successfully completed their internship, only then would they be qualified for acute care Nursing Jobs and be counted as FTEs in staff scheduling. If an intern isn't ready to fly solo by the end of the internship, they can apply for another internship to hone their skills.

But who would pay for such an internship? If basic RN training were shorter and required less clinical time, then student/school costs would be lower for the basic RN training. And it wouldn't create a delay in time to actually working as a full-fledged RN in a hospital.

I can see many objections and problems with such an idea besides the fact that it's much too drastic to expect any time soon, if ever. Liability issues? I can only imagine. Potential for hospitals to take advantage of interns if unpaid. Unmanageable costs if hospitals were expected to pay even just an token stipend for supernumary (sp?) nursing staff. And a list of other reasons it could never work that goes on and on.

For whatever reason, I find these issues interesting and find myself mulling over these impossible ideas. Hope I didn't bore too many of you out there! : )

[Dragonnurse1, ASN, RN]

Kiringat the big duh's you will get easily enough like a patient coming thru triage with a 42 o2 sat - 38 by blood gas. chest white out and she is chf patient. That you will get. It is the more sutle patients. The ones that got off the bus at 1 am with dumb or weird complaints. Or the muchousen (sp?) syndrome. Sure the patients will tell you one story and the ED MD another - patients lie - it is a known fact.

Your ER md can be a big help just do not let him yank your chain. I worked with one of the least liked ER docs and I enjoyed it. He expected you to do your job - he wanted me to dress a burn patient and said do this, no do this, not that way and I finally said "well if you make up your damn mind I will finish this" the pt started laughing and He never gave me any grief.

Remember this one little thing you have 2 ears and one mouth so you can listen twice as much AND if you have team nursing follow someone that has gobs of experience. And vent, if something is making you crazy find someone who will listen, other nurses on your shift might want to vent to. Keeps you sane

[booshieRN]

Dear Nurse Educator,

Skills take time to acquire, and , as with many things, the more practice you have, the better you become at skills.

Assessment may come easier to some. Definitely problem-solving, time-management, and organization are important. Also. listening to the patient is very important. They have been dealing with thier medications and disease processes longer than we have, and they know thier bodies. It is also a sign of respect.

I don't know anyone who has been "counseled" regarding not performing skills correctly. It will come with time.

The best advice I can give to students is to ask for help with any skill that you are not comfortable with. Never risk someone's health and safety if you are unsure. Give yourself time to grow into your new role. Be patient with yourself.

While ther are many excellent nursing schools, nothing can prepare you for the reality of the floor except the floor itself!!

I would suggest encouraged your calss to perform case studies, work in groups to try to have them practice some real-life scenarioes..i.e. listen to taped report...practice taking off orders, or ask them what orders they would expect for a specific dx..and why. We did this in my last semester of nursing school and it helped tremendously.

GOOD luck to all nursing students :heartbeatBELIEVE in yourself !