What is it really like to be a new graduate nurse????

Havin' A Party!, ASN, RN · Jul 31, 2004

... The care plan is overused and every nurse I know says they are totally unhelpful...

Maybe a tad exagerrated, no? :)

Cewens · Jul 31, 2004

I think it is great you are researching our experiences and how they could help in Nursing Education. I am a new BSN grad from ICN, Washington State University, have been on the job only 4 months on a busy Renal Unit. Nursing School did not prepare me for the amount of organization skills, and focus required daily, nor the ability to handle stress. I managed to get 3.87 GPA, but still did not know my meds as well as I should, nor many clinical skills. My grades came from my ability to take tests well and express myself in writing.

I think more emphasis should be placed on learning how to handle pressures and work as a team with other nurses, making physician contact, organizing and prioritizing your patient care, and learning to cope with angry and rude patients who are sick and tired of being sick and tired. I think Patho-Trees were great, but way too much time was spent on 10-15 page Care plans. Put students on the floor instead! I had worked as a NAC before and was accustomed to some of the rigors required but had never been exposed to so many angry patients. At first I took it very personally, but now I am learning how to let their comments roll off, have tougher skin, and continue to objectively give their nursing care. Psycho-social skills have become hugely important in my Nursing experience, at least on my Unit.

Another point is that new grads expect that they are prepared when they hit the floor and usually have a rude awakening. New nurses need to realize that they are essentially starting a "new school" called REALITY...which is much harder than Nursing School. They need to be easy on themselves for a while and realize that it will take at least a year to feel confident as a new nurse.

I believe that more clinical time is necessary to expose nursing students to these areas. I don't know how to fit it in, but maybe some of the classes such as Ethics and Gerontology can be combined with real life experince in Acute Care, ED, or even at Nursing Homes. Cultivating supportive nursing staff at the clinical sites makes a huge difference. I experienced one Nursing Instructor from my College who works on my floor who seemed to take a less than supportive attitude towards my "lack of experience," and I thought how odd and sad that she could not carry her mentoring abilities into real life.

oldiebutgoodie, RN · Jul 31, 2004

Maybe a tad exagerrated, no? :)

Nope...I have yet to meet a nurse who thought they were helpful.

OBG

Hellllllo Nurse, BSN, RN · Jul 31, 2004

How many of you have standardized/computerized care plans in your facility? Do you think having standardized care plans in nursing school would work as well as developing your own?
Could we replace it with developing some sort of critical thinking exercise, case study etc.....?

We do not use physical care plans in any form where I work.

We use internalized care plans. Here's what I mean-

I agree w/ the poster who said that care plans are vital for developing critical thinking. Experienced nurses have fast-action, abbreviated care plans in their heads. No need for working nurses to write them down or even look at a care plan.

However, I feel that writing care plans does help student nurses to internalize nursing interventions.

For example: When I am assigned at pt who has just had a CVA w/ hemiparesis, a plethora of interventions and what to watch for immediately comes to mind-

High risk for aspiration, skin breakdown, contractures, safety and mobility issues, self care issues, fear, depression, etc.

I'll need to make sure that the call light is always placed on the pt's unaffected side, within reach, taped or tied to the bed rail so it won't fall. Bedside table, phone, etc., need to be placed on the same side.The pt will not be able to get to the bathroom, and may be incontinent. Frequent toileting, skin care, turning and repositioning will be needed. If pt is dysphasic, I will need to ask "yes or no" type questions. If dysphagic, I will need to make sure liquids are thickened and diet is correct. Pt will probably need to have HOB slightly elevated at all times. Pt will be at risk for developing contractures. PT will be needed. Also, pt needs to be taught to do their own ROM exercises using their strong side to excercise their weak side. This helps the pt to take an active part in their care and not feel so dependent. Also, staff will probably not have time to do ROM w/ the pt, anyway.

Pt may be very fearful and depressed. Having CVA is not like needing your gallbladder removed. A CVA can change a person's whole life.

The pt will need to feel staff is sympathetic, caring, and concerned about him. Staff should be reassuring to the pt.

etc., etc., etc.,

Writing care plans helps nurses to learn these things, and be able to just know what a given pt w/ a given condition or multitude of co-morbidities may need.

My school of nursing was a very dysfuntional place, with cruel instructors where all unfavored students were cast into outer darkness where there was great weeping and gnashing of teeth......

I wish I could have gotten my education is a positive, pro-nurse, pro-student environment. Instuctors can be kind and helpful without lowering standards.

A class or two on charge nurse and supervisory skills would have been of great help. Also, conflict resolution.

And- how about a reality based "Trends and Issues" class?

Subjects covered should include purposeful short-staffing, staff pt ratios, disruptive physician behavior, insubordinate CNAs, crazy, angry families, how to spot a pro-nurse facility, how nurses can become activists to improve working conditions, how to protest an unsafe assignment and a nurse's legal rights in such a situation, and on and on.

Laura Gasparis Vonfrolio's "Nurse Abuse" and "25 Stupid Things Nurses do to Self-Destruct" should be required reading for all nursing students!

Nurses are sent forth into the battlefield of nursing, unarmed.

J Lynn · Jul 31, 2004

Everyone's posts so far are "right on". Since i'm fresh out of school, I would like to add some things. Yes, I know I went to PN school...not RN school, but let me tell you what they told us along the way. We were constently compared to what RN's could do. "You need to learn how to start IV's, but some facilities won't allow you to do that." Or, "You need to know how to write care plans, but usually RN's are the only ones who do that." We spent so much time on care plans, staying up late at night to finish the "book" of documentation that had to be graded, not to mention, we had to hand write drug cards. Back and front of a 5x7 index cards on one drug and sometimes our patient had 12 or more drugs.

We learned NOTHING from this. We were not taught how to give a proper head to toe assessment, I don't think I would know how to give CPR since we practice on dummies in groups at 1 hour each (over 1 year ago). My math skills are horrible......we learn medical math in 2nd semester, then went into the hospital 3rd semester and hardly had to use the math b/c everything was already figured out.....but when the time came.....we didn't remember what to do.

I'm going to stop b/c this is becoming my own personal vent journal. I guess I'm frustrated b/c I haven't worked as a nurse yet, and I feel like the only thing I learned in nursing school was where the elevator is in the hospital.

My advice, if I could teach a class of eager nursing students is to give them a full patient load, make them work 12 hr shifts, only give them 15 min lunches, no smoke breaks, but I draw the line at no bathroom breaks.....when I gotta go, I gotta go. It only takes me 30 seconds to pee :rolleyes: .

maggiechan · Jul 31, 2004

I have just finished an ADN program, which for the most part has given me good experience. As for my wish list:

1) Decent testing - well-written tests that truly test my knowledge, and don't just satisfy the whims and/or idiosyncrasies of my instructors.

2)Do Basic Assessment in the first semester - a whole seminar class would be appropriate. As another poster said, if I have to spend 1 or 2 semesters perfecting my bed-bath skills, then it would be a great idea to teach me really well how to assess.

3) Progressive build-up in clinical skills on the ward- progress within a time frame from ADLs to PO meds to IV/parenteral meds to procedures ( dressing changes/ foley insertion/ trach care/ ostomy care) ( whatever is available) culminating in 4 patient assignments and management of UAPs or LPNs, whichever is appropriate. Have a prescribed clinical blueprint so that each student knows what their goals are for that particular rotation - nursing students are typically so well-motivated that they will make sure of their own learning.

4) Care plans are a great idea if taught and used appopriately. Why not teach the principles first and then split students into groups and do case studies on certain often-encountered disease processes? It would be interactive and really encourage learning.

addendum - the first time I went into a patient's room I had NO idea what I was to do, nor what my goals were for the day. I'm not stupid, I tried to clarify this matter, but was shut down by my instructor and ridiculed for not paying attention in class. ( As an adjunct instructor at that time, she had no idea what went on in our lectures). I graduated with a 4.0. I am still furious about that experience. EVery person in 2 clinical groups (and probably more than that) complained about that adjunct instructor. She was promoted and made senior 1st year instructor the next semester. My experience in Nursing school was that the faculty did not respect the students. It has been the most frustrating experience of my life. I also hate it when certain instructors pretend to know science when in fact they are clueless. People should not try to teach stuff they don't understand - if nursing instructors don't understand something they should research what is important to the lecture and, more importantly impart the knowledge requisite to being a good nurse, and then refer students to an alternative source as necessary.

Sorry to rant, but this was from the heart.

profjanmc · Jul 31, 2004

I am sorry to hear your program had some less than excellent role models for you. I am in no way going to try to justify these behaviors, they should not be acceptable. Listening (actually reading) the passion, I am more convinced that we need to change the status quo in our nursing programs nationwide. Listening to your input is incredibly valuable, keep going....it's therapeutic;-)

Altra, BSN, RN · Jul 31, 2004

I agree w/ the poster who said that care plans are vital for developing critical thinking. Experienced nurses have fast-action, abbreviated care plans in their heads. No need for working nurses to write them down or even look at a care plan.
However, I feel that writing care plans does help student nurses to internalize nursing interventions.
For example: When I am assigned at pt who has just had a CVA w/ hemiparesis, a plethora of interventions and what to watch for immediately comes to mind-
High risk for aspiration, skin breakdown, contractures, safety and mobility issues, self care issues, fear, depression, etc.
I'll need to make sure that the call light is always placed on the pt's unaffected side, within reach, taped or tied to the bed rail so it won't fall. Bedside table, phone, etc., need to be placed on the same side.The pt will not be able to get to the bathroom, and may be incontinent. Frequent toileting, skin care, turning and repositioning will be needed. If pt is dysphasic, I will need to ask "yes or no" type questions. If dysphagic, I will need to make sure liquids are thickened and diet is correct. Pt will probably need to have HOB slightly elevated at all times. Pt will be at risk for developing contractures. PT will be needed. Also, pt needs to be taught to do their own ROM exercises using their strong side to excercise their weak side. This helps the pt to take an active part in their care and not feel so dependent. Also, staff will probably not have time to do ROM w/ the pt, anyway.
Pt may be very fearful and depressed. Having CVA is not like needing your gallbladder removed. A CVA can change a person's whole life.
The pt will need to feel staff is sympathetic, caring, and concerned about him. Staff should be reassuring to the pt.
etc., etc., etc.,
Writing care plans helps nurses to learn these things, and be able to just know what a given pt w/ a given condition or multitude of co-morbidities may need.

Agree. Believe me, I'm not filled with gratitude for the experience at the moment when I'm still up at 2:00am completing all 18 pages of this wonderful learning tool, :rolleyes: but I do see its value.

After reading some of these responses I feel pretty positive about the way my school handles things. We are assigned up to 3 pts. during our med-surg course, and carry a full pt. load of 4-6 with an RN preceptor during the last 6 weeks of our program (40 hrs./week) so that we have some experience in organization & time management.

I do wish that more of an effort was made to make sure that all students get an equal crack at various procedures. For example: we split into 4 groups for the final year to rotate through the specialties - peds, psych, L&D, and critical care. We don't learn to start IVs until we get to critical care. So the students that, by luck of the draw (no pun intended ... :chuckle ), have critical care in the fall can start IVs on L&D pts., but students who have the other rotations first cannot.

I am starting to occasionally get a knot in my stomach as graduation draws closer - thinking about all the little things I ask my instructors - in a little over 10 months I won't have that safety net anymore.

JacelRN, BSN, RN · Jul 31, 2004

I would like to further address the care plans. My best instructor in college changed the way we had to do care plans and I loved it. It is a new model used currently in many nursing schools. We draw a stick figure of a patient in the center of our page and draw or print from a computer 5-6 nursing diagnoses in red ink. Those are bubbled in and from that we spiderweb out created a plan of care, lab work, medications, procedures, etc. While I found this new careplan to be an excellent source of book knowledge and organization for me, I believe we concentrated too much time and energy just on creating them. Our grade depended upon the accuracy of this paper. The instructor could have used it for so much more. Once it was finished, I breathed a sigh of relief. The next day at clinical I would follow my care plan going through the motions like I was a robot following commands from this piece of paper. No real learned knowledge came from it in the clinical sense. I was not shown the full picture of my patient's diagnosis in practice. What I did learn was how to relate to my patients. I learned how to ask the right questions and do a decently organized assessment. Working one on one with patients will always be the best source of information, especially with a cooperative patient who likes students. Perhaps the answer is more instructor's time pointing out a better way to assess or showing you something you missed. Not so much as a punishment by grade but in a effort to teach. Trial and error (safe error) is an excellent way of learning.

I also agree with the other posts regarding the mental preparations a new grad must make. Every day I feel like I must prove myself as a new nurse. I go through my checklists and do all that I can remember before leaving. I try not to leave anything for the next shift. While I do this not only for the patients, I also do this to avoid someone saying "you didn't change her depends and she soaked the bed." A lot of shift blame goes on in the hospital and I try my best to avoid it. I also do my best to tape report consisely and efficiently. I'm glad their is a pause and rewind button to tape over my mistakes. I still feel as if this is a skill I learned on the job as we didn't tape reports but gave limited verbal reports in school. Many new grads feel this way but may not admitt it. There is also the problem of dealing with the other nurse's attitudes and the irate/combative patient. We are only taught by mention in school how to deal with this. Therapeutic communication should involve all aspects of nursing, not just the patients.

Overall, I would have liked to have learned a broader aspect of what it took to be a nurse once I graduated. I was taught the meat of what nursing is and for that I am thankful for a committed program. However, nursing is not only treatment of a disease process, it is about living the life of a caretaker.

How do I look past this patient who is snippy with me to treat them as a patient in true need of healing? How do I work professionally with my co-workers and Dr's when they yell and scream? What will 12 hours on my feet do to my body? All questions unanswered in school during the ciriculum. Perhaps seminars of these issues addressed by new grads throughout the nursing program is due. Go to the source and educate those future nurses by what we have learned through process and experience.

JacelRN

RN4NICU, LPN, LVN · Jul 31, 2004

Preventing reality shock

Perhaps the first day of classes each semester could be a question and answer session with practicing nurses who can tell students what their "real world" is like. It could be nurses from various specialties and even from different area hospitals. That way students could have a better understanding of how different various work environments can be, they can learn first-hand about specialty areas, their questions and concerns can be addressed. I would suggest faculty not try to "censor" the visitors or encourage them to paint rosy pictures, but rather encourage them to give the students the real story. This gives the students the opportunity to decide about nursing as a career. Perhaps this question and answer session could be the first half-day and the second half could be a discussion with faculty members about what was discussed earlier.

What do you all think?

wv_nurse 2003 · Aug 1, 2004

wow....I remember those first days and I still thank God I had a great boss who was more than happy to teach.
Nursing clinicals do very little to prepare a new nurse..they are too short , too controlled way too organized...too much time is spent in mini conferences with the instructor grilling and not enough time is spent actually providing nursing care.
I can remember the first term making beds and giving one bath..what a complete and utter waste of time...weeks spent worrying about a ridiculous hospital corner and the proper way to hold a washcloth...way too much emphasis placed on commen sense stuff and an insult to intelligent people..
No time spent on moving people ..in and out of bed..around the bed...how do you bathe properly, wash hair and change the sheets in 15 minutes or less..that would be something to practice over and over again since your whole career is going to revolve around bathing,moving,lifting.....making beds for weeks and then giving one bath...not gonna cut it.
Meds...meds and more meds training..don't wait for second term..start early and often...meds every clinical day..this is the biggest area of errors in the nursing profession...nursing school needs to indoctrinate safe meds....the only way to do it is to DO IT...not just one day or one week...every year every clinical...meds meds meds
Scrap some of the neverending ethics classes...teach ethics on the floor...real world ethical and moral debates when they occur...ethics in action with patients,nurses,doctors and families
How about teaching nurses the reality of working with doctors....prepare them for that moment when a doctor hangs up the phone or patronizes you in front of your peers or yells , throws things or calls you names.
How about teaching nurses about other nurses and that they won't be thrilled to see you because it means more work and they don't trust you...
Nursing school is a fairy land where all you have to do is make sure your clinical instructor likes you even if she is a psychpath and you have to tell her everyday she is God's gift to nursing to do it...and I had more than one of those. It was good practice for nurse managers...maybe you should also cover them too...they are not your friends...the union is your friend..your manager is the enemy, don't be shocked when they pretend to be your friend while cheerfully complaining about you to everyone they meet, they are masters of the passive aggressive.
If new nurses understood the realities they wouldn't get so upset...knowing your reality means you can prepare for it and get over it quickly and move on...it can be considered a nuisance instead of a devastation of ego.
Nursing students need real world experience...sitting in a class room practicing putting in a catheter is a complete waste of time.......noone looks like that plastic groin...instructors should be agressively proactive on the unit..every catheter should be a learning experience...be like docs...see one do one teach one..skip the neverending six week how to do a dressing...find a patient and show..teach on a real wound...show how to clean..tape...where to put your dressing tray when there is a lunch tray and nine paperbacks and three flower vases taking up all available room.
Real world teaching over and over and over so it becomes memory..all nervousness gone because you have done it a hundred times on a real person.
Stop wasting time on the "perfect" dressing change that must be graded and critiqued...concentrate on hand washing and how to use sterile gloves...this ridiculous concentration on sterile technique is just an intimidation tactic that freaks out students......try to remember the patient is NOT sterile...good handwashing technique is the answer to a multitude of sins....if you break sterility with filthy hands? bad news..but if your hands are clean or even better clean with sterile gloves on?..well everyone can relax.
Emphasize errors will be made but if your hands are clean the end of the world can be averted.
Use common sense. avoid scare tactics...explain why things are important without invoking terror tactics...teach ORGANIZATION...how to plan your day..how to de stress and how to let the unimportant things go for another day
Good handwashing..being organized , excellent med skills and being good and fast at giving a bedbath will make a new grads life a lot easier.

This sounds like what my diploma grad friends describe as their shool experience..... :)

LPNalmost! · Aug 1, 2004

Amen, Amen, Amen!!

I am 6 weeks away from graduating from an LPN program. I have given 1 IM injection, D/c'd one IV, no "sterile" dsg changes, and inserted no Foley's at this point. But by golly, I have given one to two bed baths every Monday, Tuesday, and Thursday since January. I think I've got the baths down at this point!! Really, really not feeling like I'm prepared at this point to enter the real world. And I'm one of the top 3 students in the class. I really don't know what's going to happen to the rest. I guess we've all got a future as CNA's 'cause we're really good at bathing and bedmaking. My corners are "sharp"!

Thanks for asking!
Although I am not a new grad (I'm halfway through a program). here's what I can say so far:
1. Lose the weeks and weeks of bed baths. After 3 or 4 weeks of baths and bedmaking, I think we can move on. My program gave us a whole term of this, which I think was a waste of time. Their rationale was that we can do a thorough assessment. That sounds good, except that we didn't have the Health Assessment class until the following term.
2. Start giving meds and injections as soon as possible.
3. Don't yell at students who are doing sterile procedures. It doesn't help our learning, and frankly, I doubt the patient will die if my hand happens to move over the sterile field. (not touching it, just above it). Remember how hard it is to grow bacteria in Microbiology class?
4. Let us do more procedures, less care plans. The care plan is overused and every nurse I know says they are totally unhelpful.
Thanks for listening!
Oldiebutgoodie