Why are so many new nurses having problems?

pcornwell · Jul 2, 2011

This subject would make a good thesis topic.

I think this forum really isn't a place where most people come to praise nursing but a site to find comfort and understanding regarding issues with nursing. A study would be very benifical in determining what is really going on with job satisfaction for nurses.

eslvn · Jul 2, 2011

I have often wondered this as well. I am a new nurse myself ( about 6 months) and I feel that nursing school does not teach one to be a nurse, it only gives you a foundation on which to build on. I dont see how is could be any different though. Nursing is a very special profession, and I think experience is the only thing that can teach us. I dont feel that I got adequate orientation, there are a lot of things that I wasnt sure of and I decided I would just ask questions no matter how dumb I felt. I think part of the reason nurses have so many problems adjusting is lack of confidence, and how terrified we are. In school they tell us all the ways you can have your license revoked, how easy it is to cause someone harm, and so on. With all the lawsuits going around, a genuine mistake is unforgivable. However it isnt exactly that extreme. Anyways, I have often wondered the same thing, and I am not sure if this is how it was 20 years ago or if nurses then felt more prepared, or if things in the work setting were different. Maybe its all the dang charting?

nohika · Jul 2, 2011

I think part of it is indeed the shift in education. The older programs were three-year diploma programs where literally you worked in the hospital your entire education. You came out ready to simply hop into a staff role - you could already handle the pt load, the charting etc.

Nowadays students have far less clinic time (one to two days a week) and there's more of a focus on "book" learning due to the NCLEX.

Dixielee, BSN, RN · Jul 2, 2011

I think a lot of it has to do with the charting requirements. I have been a nurse a long time and have seen many trends come and go, but the electronic charting is a disaster. If I have a critical patient, I have to decide if I am going to treat the patient or treat the chart. Of course I treat the patient, but things go uncharted, so it looks like things were not done. Our particular system Cerner/First Net is tedious.

In addition, we now use a PPID system for generating labels for labs. It too, is tedious, often doesn't work and is time consuming. We are soon going to a similar system to give meds. I think this will make us all work as if we are in quicksand.

I work in a very busy trauma center ED, with over 100 beds. We have not implemented it yet, so I'm not sure of the logistics but I have taken the online course info on it. We have to log in, scan the meds individually (but first an order must be in the chart, and we often need to give meds before we enter the order), scan the patient....if a med doesn't scan (and the packaging is getting flimsier and more cumbersome), we have to send it back to pharmacy with a note saying it won't scan, the administer the med, then chart it.

I'm not looking forward to this. I think this kind of stuff continually slows us down in the name of patient safety, but how safe is it if you are bogged down scanning meds when you have patients requiring immediate attention and there is no back up??

Oh well, just my thoughts on the new trends in nursing that are certainly not in anyone's best interest!

jennyb76 · Jul 2, 2011

i start nursing school in the fall, and reading a lot of the forums on this website about new grads' horror stories about the first year after licensure and/or inability to find jobs is really scary/discouraging!

raskol · Jul 2, 2011

I have to question the type of students coming into nursing as perhaps part of the problem.

Are they compelled by a strong desire to "help" people. Perhaps the reality of documentation and medication administration bog them down.

Are they motivated by the idea of job security? Has the economy decreased their ability to find a desirable job and the tough environment hit them unexpectedly?

Are nursing schools accepting students who have no business being nurses, and furthermore not kicking students out after serious violations?

Do students find nursing research to be a boring class and not understand the implication to practice?

I don't really know. But I feel as though students go through nursing school with no true appreciation of how the profession is run and are throughly disappointed with reality.

NannyG16 · Jul 2, 2011

Fascinating questions.

I have been a nurse for almost a quarter of a century, and I will say this:

First off, while I'm not by any means condemning the "entry level BSN" mindset, I think that it leads to many new nurses seeing bedside nursing as a stepping-stone-- a "necessary evil"- to what they REALLY want to do with their degree (management, more school for an advanced degree and an NP role somewhere...). In the old (OLD) days, I think many nurses wanted an entire career at the bedside.

Also, I think bedside nursing these days is quite challenging... all about money for the hospitals... with Medicare calling so many of the shots. Where I work (on a tiny 10 bed Ortho unit) 2 nurses can share 9 or 10 discharges (and 9 or 10 subsequent fresh post-op admissions) every three days! It's all about pathways and a "get'em in, get'em out, get'em in" mentality. It's really no place to LEARN anything, no place to TEACH anything, no place to be on those days that you wish for the luxury of TALKING to your patients, or feeling that you've done anything above the bare-bones minimum. I know that when I got out of school, I wanted to help people, and I don't often feel that I do a lot of that where I am (my patients say I do, but I don't feel it). I can't imagine walking into this job as my first job- YIKES!

And, finally, the previous writer mentioned lawsuits and the paralyzing fear of making a mistake. I feel that with the shear volume that we see, the chances of making a mistake are increased... along with the fear of hurting someone and having a disciplinary action against your license.

I will finish by saying that, before I relocated to another state, I was lucky enough to spend the first 20+ years of my career at a very large urban teaching hospital. Everyone that I ever met there was happy to help.....to teach, to wait for you to "get it", to teach some more. Staffing was great. Acuity was very, very high, but we had the time and the staff to do the job well. I think that if every "first job" was like mine, more new grads would have the chance to develop a true love for bedside nursing, and would be likely to spend a career there.

Thank you for posting this very interesting topic!

NurseSnarky · Jul 2, 2011

I think a lot of it has to do with the charting requirements. I have been a nurse a long time and have seen many trends come and go, but the electronic charting is a disaster. If I have a critical patient, I have to decide if I am going to treat the patient or treat the chart. Of course I treat the patient, but things go uncharted, so it looks like things were not done. Our particular system Cerner/First Net is tedious.
In addition, we now use a PPID system for generating labels for labs. It too, is tedious, often doesn't work and is time consuming. We are soon going to a similar system to give meds. I think this will make us all work as if we are in quicksand.
I work in a very busy trauma center ED, with over 100 beds. We have not implemented it yet, so I'm not sure of the logistics but I have taken the online course info on it. We have to log in, scan the meds individually (but first an order must be in the chart, and we often need to give meds before we enter the order), scan the patient....if a med doesn't scan (and the packaging is getting flimsier and more cumbersome), we have to send it back to pharmacy with a note saying it won't scan, the administer the med, then chart it.
I'm not looking forward to this. I think this kind of stuff continually slows us down in the name of patient safety, but how safe is it if you are bogged down scanning meds when you have patients requiring immediate attention and there is no back up??
Oh well, just my thoughts on the new trends in nursing that are certainly not in anyone's best interest!

This is OT, but I just had to jump in and say the scanning of meds when I worked ICU is why I quit the position a few years ago. The expectation of job duties and scanning the patient, scanning the meds, if the order wasn't in then explaining (in paper writing) why you needed to do an override (because a patient just arrived from cath lab in extreme pain and needs some morphine asap, and where I worked you had to scan a flush all added up to I'd had enough. I've worked with various types of computer charting, but it's gotten to the point where you are sitting at the computer more than patient care.

On the topic...I did not feel prepared for what was expected of me when I started my first position. And I was an older new nurse as well. I stated this before I graduated and even filled out a survey that was being conducted by a big university after I graduated. Clinical time was too short and did not reflect what a real patient load and expectations would be once we had jobs. At my first position my preceptor was young and was not cut out to be a preceptor (but she was an excellent nurse). She wanted to be done at the end of shift, no exceptions. So I spent most of my orientation running around after her. Again I was not prepared mentally to take on critically ill patients. My sup told me I was doing excellent, but I felt completely overwhelmed and left before my year was up. After that I started in PACU/OR and felt at home for me. I also made sure I had a dedicated preceptor and spoke up if I felt things were too much. I still do. I don't care how it appears to others (weakness or whatever). The see one, do one, teach one mantra? Good in theory, but a lot of things some of us don't catch on the first go around. It all depends on if your brain cells have had enough. I wanted to leave nursing so many times. I've taken some breaks too to gather myself together and to ask "what's up?" When I went to school I can look back now and see that it felt like the schools were trying to churn out as many nurses as possible in order to fill a shortage. We could pass NCLEX first go around at 75 questions, but could we take a patient load of 6-7? I did not feel confident that's for sure. I was told by a nurse once that you're not a real nurse until you hit the 5yr mark. I took great offense at that for the longest time as I thought NCLEX and a job made me a real nurse and then after that first year, that would make it official. But the amount of time needed to get that experience...it can be about 5yrs. Some can get "there" sooner, some might be later. They don't tell you in school you need much more experience in order to feel more confident and settled. They let you think videotaping yourself doing skills is enough. NOTHING replaces hands-on experience, real life experience. And I'm talking let the nursing students DO THE WORK. So many of my clinical times were viewed by nurses as a pain in their rear. Slowing them down...so we didn't get a lot of hand's on experience. It's hard when your routine is broken, I get that...btdt when I precepted. But then clinical sites or the program itself needs to be more scrutinized.

I guess I could go on and on...but this is not new and it's also not being fixed.

kalevra, BSN, RN · Jul 2, 2011

I think part of it is indeed the shift in education. The older programs were three-year diploma programs where literally you worked in the hospital your entire education. You came out ready to simply hop into a staff role - you could already handle the pt load, the charting etc.
Nowadays students have far less clinic time (one to two days a week) and there's more of a focus on "book" learning due to the NCLEX.

I remember going through orientation for the RN ADN program, instructors told us "We cant tell you to buy the NCLEX study materials now but we highly recommend preparing for the NCLEX now. Our school also has a 92% NCLEX-RN first time pass rate that we expect to continue to improve".

Clinicals for us are 2 days a week for 9 hours a day. Then there is the one day of lecture for 5 hours.

canesdukegirl, BSN, RN · Jul 2, 2011

there are some great answers from the above posters. very well thought out and insightful. kudos to y'all!

i will try to answer some of your questions without rambling...but no promises :)

so,

my questions are:

1. is this a new problem, or has there always been a group that just doesn't "fit" or has trouble transitioning? maybe it's just the connectedness of the internet that makes it more apparent.

there is always a group that doesn't 'get it' as fast as others. it could be chalked up to a myriad of reasons. i have had a few new nurses whom i precepted that were disasters in the beginning. they were much too frazzled to learn. after i reassured them that i would not let them fall and taught them some quick deep breathing methods, they started to retain more. you can't learn if you are terrified. in a few months, these new nurses were absolutely terrific, and one of them was running circles around me! i love seeing this growth. i believe that a huge part of the problem today is simply the lack of time that we have to do anything but pt care-with no time to teach adequately.

2. has the shift in education toward nclex changed how prepared students are for actual work? you always hear "you learn how to learn" or "you learn critical thinking in school" and the other stuff you learn on the job. but

i can't really answer this one. yes, you learn critical thinking in school, but you also must learn 'nurse instinct'...for example, when i rolled one of my pts back to the or, i didn't have a wonderful feeling about how smoothly things would go. there wasn't really anything glaring in this pt's hx that would give me this feeling. there were minor problems, but overall this dude was healthy. i just didn't like the way he looked. so i rolled the crash cart just outside of the or just in case. we had to use it.

3. is it the lack of training through preceptors, residencies, etc.? many new grads are going into regular positions with very little orientation time and no support system. so they aren't being "taught" but thrown in to learn on their own.

yes! this is a big problem. i wish that every hospital required new nurses to go through a residency program, but many small hospitals don't even have a formal orientation program. they just stick a new nurse with whomever is working that day. this is terribly frustrating for the new nurse. we all need to be led when we are learning something. the lack of consistency in preceptors is also another problem that i have heard voiced many times from our new staff members. i think that our nurse educators should be more visible on the unit itself instead of in an office somewhere 'close' to the unit.

4. have the conditions on the floor changed for the new grad> more patients, low staff, high acuity, etc.? how does it compare to conditions 5, 10, 15 years ago?

when i first started 13 years ago, the normal pt load was 5. that was considered a full load on a med/surg floor that shared beds with onc. the acuity of our pts were high, but the assignments were well thought out and divided evenly. we typically had 1 easy post op, 1 chemo pt, 2 med pts and 1 'difficult, demanding and manipulative' pt that took up the time of 3 pts combined.

now i am seeing hospitals cut support staff, so that nurses must also be secretaries, it experts, biomed maintenance staff, and social workers. our work has increased slowly but is now at the breaking point. as several other posters have stated, we can't be enslaved to the computer/printer/scanner when it breaks or malfunctions because we have a live human being that needs our attention. i'm gonna pick the live human to attend to instead of the freaking technology that has so greatly enhanced and improved our working conditions. i can use good ol' pen and paper and pick up the phone like we used to do. i didn't go to nursing school to become an expert in technology.

5. has the average nursing student changed? is the motivation to go into nursing different than before? i was not motivated by "a dream" but by the interest in science, psychology and working with people. does this affect our ability to "stick with it"?

i don't really know. i haven't personally seen a large trend in the way nursing students behave. i have seen more entitled attitudes, but by and large, i think that most nursing students share your interest in science and humanities. i don't think a particular motivation would affect your endurance-if you love what you are learning, you will clear the hurdles and the growing pains will abate once you get the hang of working on your own.

6. has there been a shift of mentality? "life is too short" kind of thing. are we more likely to change when things don't go as expected or don't meet our needs? this could be good or bad.

oh sure. i think that a lot of what you are referring to is the 'instant gratification' that our society demands these days. there are some that think nursing is too difficult at first...because it is...and don't weather the storm long enough to experience the nice calm seas that come afterward. have you ever been completely frustrated when you first started to learn something-to the point of crying almost-and then after you have mastered the task, you wonder what in the hell you were so bent out of shape about? same mentality. it takes a while to get the gist of nursing. it is so worth it if you stick to it.

Tait, MSN, RN · Jul 2, 2011

I think nursing has just overall become harder.

Overall I think the following:

Patients are sicker.
Patients are increasingly complex with comorbidities.
Medication regiments have increased in complexity as people are prescribed more and more medications at one time.
Charting has to be extremely concise to CYA.
Monetary issues increase nursing stress by decreasing resources.
Patients are more "Google Educated" which leads them to challenge our knowledge more, sometimes for the better, sometimes for the worse.
Expectations are higher for amazing outcomes, while resources continue to dwindle.

Education has changed as well. Even though I feel I had a great experience in nursing school, with very adequate clinicals, I marvel when Philippine nurses talk about camping out in maternity wards to get their mandatory 32 or so live birth experiences. (I never even got to see a birth in school! My own will be my first experience!) Sometimes I wish I could have gotten a diploma degree because the experience of being in the hospital, living and breathing that environment seems like such a great way to really learn.

Nursing has always been a very difficult profession, I am not denying that, I just think the complexity has really been turned up, leaving many of us scared, threatened, and burnt out. Young and old school alike.