Monthly Archives: May 2012

how to boost your NCLEX score by twenty per cent

NCLEX fever

This blog entry goes out to all those persons who are now studying for NCLEX.  Congratulations on completing your basic nursing education. Why not treat yourself to a great beach read, and buy my book about nursing in Nepal?  the book itself won’t help you with NCLEX but it will get you to think about something else for a while….

NCLEX secrets

I confess that I get annoyed when I see people studying for NCLEX by reviewing page after page of question in some popular NCLEX books. I wonder whether you achieve a greater comprehension of the underlying material that way. I always compare this method to that of doing crossword puzzles. it keeps your mind busy – but will you be a better nurse? the nursing process is not a collection of sound bites or factoids.

your school wants you to succeed

every nursing school keeps track of the first-time test taker pass rates, and there are mechanisms in place to make sure that they are preparing you for what you will need to know. One question that students do not often ask is, how does NCLEX decide what to put on the exam in the first place?  the answer: NCSBN tells them.

Alphabet soup NCLEX and NCSBN

NCSBN is the National Council of State Boards of Nursing, and if you go to their website, you can read the test blueprint for the NCLEX exam. NCSBN periodically surveys nurses, schools and hospitals around the country, to gather info as to what “any prudent nurse” might be expected to know, and uses this to adjust exam content accordingly.

A 65% pass rate is also a 35% fail rate

A few years back I taught at a school of nursing that was deeply concerned about the pass rate of the class they had just graduated. When a student does not do well on the exam, their focus is on what they did; but from a school perspective,  nobody wants to get calls from angry parents, the Board of Nursing,  or the college’s Board of Governors about the pass rate. When this group of seniors did so poorly it led the school to organize lots of work to revise things and look at what to do.

my own two cents – delegation

I joined that school right after the exam debacle, and I was to teach the leadership and management class. ( I have ten years of hospital middle-management experience.) I did some specific research, and analyzed the existing class syllabus to see what emphasis was being taught. I concluded that we could benefit from beefing up the content on the subject of – delegation.

history of delegation content on NCLEX exam

It turns out that in the mid-nineties, feedback to NCSBN was that new graduates needed to be strong on delegation skills, and NCSBN asked for a higher percentage of the exam to be devoted to this subject area.

three questions

a) if you knew that up to twenty per cent of the NCLEX could be devoted to delegation, wouldn’ t you want to study it more?

b) if you knew that NCSBN did a specific fortyone-page paper on the ins and outs of delegation, wouldn’t you want to know what was in it?


c) if NCSBN developed a teaching program on delegation, wouldn’t you want to study that? These are the same folks who said that delegation is an issue, after all. )

My answer to all three was yes. Most textbooks of nursing management cover delegation, but they tend to limit it to four or five pages; my advice is to find the source document from NCSBN and to download the whole thing ( it’s free). Study it from there.

how is your assertiveness skill today?

One of the best and most cogent points made by NCSBN in their paper is that the best rule making related to delegation ( having the best rules in place) is not helpful unless the nurses who are supposed to use the rules for patient care also possess the interpersonal skills to deal with conflict resolution and problemsolving. A surprising amount of the forty-one pages is devoted to ways to communicate effectively in situations where a licensed person is directing unlicensed personnel. The rules are designed to support the RN but if the RN does not assert themselves it’s a problem. Being assertive is not the same as sparking a confrontation. ( see note below – Thanks JPA!) nurses are sometimes so afraid of confrontationthat they won’t speak up even when warranted.

NCSBN even gives you role play scenarios to use in class when you teach this.

final words

in the previous blog entry I wrote about summer internships and being a good follower.  the paper on interpersonal skills applies to you right now as a student nurse and if you communicate effectively you will stand out from the crowd. start reviewing it now and you will be that much further ahead.



Filed under NCLEX, nursing education, Uncategorized

How to succeed at a summer nursing internship

this book is about medical missionaries in Nepal. sure to become the number one beach read for summer 2014! go to Amazon and pre-order your copy at

this book is about medical missionaries in Nepal. sure to become the number one beach read for summer 2014! go to Amazon and pre-order your copy at

Dedicated to all those foot-in-the-door nursing students who competed for a summer internship or residency program, and got it….. hot tip: if you live near a beach and you want a great “beach read,” now is the time to buy my book about nursing in Nepal.  It will make you consider the real reason why nursing is so important. if you don’t buy the book, you can still visit my FaceBook fan page.

The problem

So a recent student came to me for advice. “I got the summer internship in the ER. Now what do I do?”

We talked. She will be at a big ER, and I’d written a letter of recommendation for her that emphasized her ability to keep track of details and to be accountable for followup. She was worried about how she would respond to all the emergencies. She is a bit of a perfectionist…

“First off, they will never put you in the emergency side, trying to figure out what’s wrong with  a critically ill person, until you prove yourself on the basics. The ER has had many other nursing students and they know how to bring you along and develop you.” this, I knew, was a deep fear: will I be able to deal with all the blood, gore and trauma? Many newbies wonder this. What they don’t know is that there are systems in place so as not to expose them to anything they can’t handle. trust me.

Repeat this mantra over and over: The rules of good basic nursing care don’t change just because you are in an ER (or ICU) as opposed to a med-surg ward.

If you are overawed, thinking you now possess magical powers, be advised: the only way to achieve magical results in patient care is through hard work by a team of dedicated nurses.

The semi-acute side of ER care

She was relieved at this.  I told her that she needed to be very careful about the  role she was in, and that not every single minute would be worthy of a TV show about saving lives. “There is always a section in any ER where the patients are nursing home residents sent there for further evaluation, such as for urosepsis or pneumonia, and I am sure they will assign you there first. You will be doing such things as delivering personal hygiene care prior to straight catheterization to obtain a culture and sensitivity. You will start off by using the exact same basic skills you would use in clinical. ”

The three things to do

Does this sound familiar to you? Here is the rest of the advice I gave her.

Road Map also known as “Nurse’s Brain”

1) continue to use a Road Map.  (see other entries on the blog). at first, you will say “no way, the whole deal is that the patients come in from scratch and we don’t have time to prepare a road map, it can’t possibly be useful” – whenever I hear somebody in an acute situation say that, my ears perk up. My reply is, keeping track of details despite chaos and a fast pace, is exactly why a road map is even more important. frankly, a person who doesn’t write stuff down is setting themselves up for failure. Your clipboard/nurse’s brain doesn’t have to have the same list of items on it that might be used in an inpatient setting, but you will still be assessing, implementing, planning and evaluating.  The road map for ER can be a simple plain piece of paper on which you write down the name and what you are told, for every patient to whom you deliver care.

Get in the habit of carrying a clipboard and writing down every thing you are assigned to do, especially if it involves followup later in the shift. you will be constantly writing little memos to your self. think of the similarities between ER nursing and being a server at a restaurant with up to ten tables of four persons each. If you were taking the order for dinner and cocktails at a table for ten,  you would write it down!  do the same here.

TIP: here is an example. for a patient requiring a workup for fever, they get a) blood drawn, b)urine and sputum samples sent, and c) an x-ray. Maybe they get d) an IV and e) one dose of an antibiotic followed by f) rechecking their vitals. So – the clerk and the RN deal with these orders, but somebody has to see that they are actually carried out. Learn the system, and use your road map to help keep track of whether the x-ray was actually done, whether the samples were actually collected, whether the results arrived back and somebody was told that the data is ready.. If all you do is to prevent your patients from becoming lost in the system, you will be making a contribution. If there are hanging around the ER very long they may also need help with food or going to the bathroom. those things, you can do.

Delegation and Communication

2) think about, and review, the rules on effective communication and delegation of nursing tasks. ( betcha didn’t know that there are rules for this!).  You will be practicing within a scope of practice, and you will only be doing those things an RN delegates to you, for which you get checked off. (for example, don’t do any appendectomies all by yourself…) Review the blog entry titled ” the unwritten rules for a nursing student’s job dedscription” – these are taken from the Marine Corps rules for sentries, and they describe basic lines of accountability. You need to become a good follower in the intern role, it will later that you become a good leader.

On the NCSBN website, there is a 40-page document on delegation of nursing tasks to unlicensed assistive personnel, titled Working With Others……   Download it, print and study it. It’s about effective communication in the clinical setting. Nobody will ask you to recite the ECG criteria that indicate possible procainamide toxicity; but everyone will want to know whether you are smart enough to know when to seek guidance or to report something weird that just happened. In the most recent ACLS manuals from the Heart Association, there is also a section on how to make sure that orders are clear during a high-pressure team response to an emergency. This is also good reading.  T.O.R.B. on steroids.


3) think about Maya Angelou, who wrote; “I did then what I knew how to do.  Now that I know better, I do better.”   Makes notes on your road map about the new things you see. At the end of each day, take the road map home and analyze it as to what to study that evening. This is an essential professional habit, some people call it “praxis” – making a structured plan for your self-directed learning then using it the next day. For example, one day you look at the road map and you realize, you were in the urgent care clinic doing vital signs and prep work for a bunch of kids with otitis media (happens all the time). how did you do and what do you need to learn? you might come up with, gee, they were all two years old, maybe I should review growth and development of 2-year-olds so as not to tweak their stranger anxiety; what is the usual medicine the NP orders; what is the dose of ampicillin for a kid that weighs forty pounds; what are the usual vitals signs, etc. If you can’t come up with these sorts of things, ask the nurses around you for advice as to what you might study. Next time you are on the walk-in pedi clinic side, you will be better prepared. praxis.

Use all resources!

If you can, bring your textbook to work. refer to it for quick look-ups when you need to. this is professional behavior, not a sign of weakness!

Or maybe you spend the day in the casting room. or an eye injury comes in and they use the Morgan Lens. or maybe nasal packing or any number of odd things. ask you self how often any given incident occurs and what you will need to know next time. then go home and crack the books.

More study out of work will always be rewarded. Sure, it is summer and you can take time to enjoy your self. but attending to these two things will pay off in a big way.

Share this

be sure to share this widely with every summer nursing intern you know; why not subscribe?

PS – if you are too young to recall the TV show ER – go get the DVDs. It was on for 15 years.  In my opinion, they had a good handle on what was important.

and yes, read my book…..


Filed under Nurses Brain, nursing education, Uncategorized

#6 – tips for teachers – are you a nag at clinical?

has this ever happened to you at the hospital?

you start the day with the best of intentions, but then – a student arrives late who didn’t call. somebody else lacks the written preparation that is part of the class. You need to remind the whole group to put their hair up. A staff nurses takes you aside to tell you that the student in room 316 left the bed “up” with the side rails “down.”  The nurse manager takes you aside to tell you that the staff has noticed that your students don’t follow the hand washing protocol. Oh and by the way, when they did pre-clinical prep the day before, they did not have a name tag and brought their lunch to the nurse’s desk.

mother, puh-leaze!

All of these things disrupt the good karma of the day, and they prevent you from living up to your potential as the warm, wise, collegial faculty member you set out to be when you decided to teach. You wanted to be able to spend time talking about the higher-level things….  showing the students something unique about the patient assigned to them perhaps, and yet – you never quite get there because you find yourself nagging.

The history – reacting against ritualism and militarization at school

We have all heard the jokes about strict nuns at Catholic Schools (not limited to nursing schools – elementary schools were included!) who expected a set of ritualistic behaviors and stopped at nothing to obtain them. For the first hundred years or so, nursing school was like that. In some parts of the world, it still is. Nursing school was like Marine Corps boot camp for many young women. When I take beginners to the hospital, I put this issue on the table. “Are nurses educated? or trained?”  There needs to be a balance. The fact is, there will always be a group of teachers who think that it is somehow beneath them to give the students feedback on simple stuff  – because the teacher is reacting philosophically against the harsh quasi-militaristic traditions in which nurses formerly needed to learn to do things a certain way.

The Paradox

These faculty are young and idealistic and they mean well. Paradoxically, their students are sloppy and the ward staff complains about them more. This is a fact of life. and the faculty says “you would think the students would be grateful that I am such an enlightened faculty member.” Nope. You need to model the right micro-behaviors from the beginning, over and over.

The fact

The fact, the sad fact, is that the student does not know any better. Don’t get into the negative spiral of blaming the student for your lack of control. All they know is, stuff keeps happening, and there seem to be an endless set of rules that nobody told them about. If the clinical experience consists of getting nagged at from all sides, students learn to dread clinical when they ought to be learning to love clinical. I wrote a previous blog on the subject of “the unwritten rules of a student nurse job description” – this blog is a continuation of that same theme.

The solution

Believe it or not, you can have clinical time in which you truly do focus on the actual patient instead of “the rules” – Don’t wait until clinical to start teaching these little micro-behaviors. You can be in control without being controlling.

the secret? use your learning lab as if it was the hospital. Establish rules at lab; enforce them; explain them there; and follow them at lab always. The lab is more than just the place where skills are learned; it is also the place where professional work behaviors are taught.


we start off the  first day of Lab saying ” you think you are at the lab, but this is actually University General Hospital and we will teach you certain ritualistic behaviors that are used in any hospital.

The rule is,

If there is something you would be doing in the hospital, do it here; if there is something you would not be doing in a hospital setting in front of patients, don’t do it here.

always wear name tags at lab.

always wear a uniform at lab. We have the clinical uniform (scrub suit) but in lab we use the “polo shirt uniform” – green polo with logo on it and khaki trousers.  Faculty wear the uniform too. closed-top footwear ( no slippers – something we need to enforce in Hawaii but probably not an issue if you teach in North Dakota…)

no food in lab

adjust height of bed high when working; low when away. side rails accordingly.

all mannikins have a wristband, and it is checked as part of every procedure.

all mannikins have a chart and there is an order in it for every skills we practice. the order is checked.

begin each run-through of  any given skill by washing hands and introducing yourself to the patient.

lounging on the bed is not allowed

horseplay is not allowed

use the over-the -bed tray to promote body mechanics.

always spend the last ten minutes cleaning up the lab for the next class.

we do make two exceptions: we don’t don clean gloves all the time (too wasteful since we are not actually in contact with anything) and we don’t always pull the drapes (so the faculty can observe everything)

In other words, professionalism in lab will pay off in clinical. you get the nagging out of the way, so that the expectations are known before you get near an actual patient.

The Nurse’s Brain

oh and by the way, you can also remind each student to add these little things to their “brain” – see the previous  entry on Nurse’s Brains….


I rationalize it by saying that though I do not wish to promote ritualistic behavior, there are certain habits that are best learned by repetitive reminders and that just because the student is getting feedback, does not reflect on whether they are a good person. “you will thank me later.”  repetitive behaviors can be “evidence-based.” go watch a clarinet player sometime: they learn how to move the fingers by practicing each finger thousands of times. The basic skills can only become second-nature if you practice them as if they were your clarinet.


this is all explained in a handout we give students at the beginning of lab. send an email to and I will send it to you as a Word document.

I will devote a future blog to a mini-theme of mine – How to use low-fidelity mannikins to enhance your high-fidelity sim-Man experience. If your school has the $$$$$$ hi-fi mannikins, you can really boost your performance by changing the way the students interact with the low-fidelity mannikins. It’s true!

Finally,  please consider subscribing to this blog, and sharing it with others.


Filed under classroom management, nursing education, nursing faculty jobs in Hawaii

#5 tip for teachers – dealing with questions in class

hey – if you like this, share with friends and subscribe. it’s easy!

Controlling the class

If you are new teacher of nursing, you will be faced with the idea of how much interactivity you wish to have in class. Will you simply stand there and lecture while the students take notes? (like a “talking head”) Do you build in some small group activity? Do you continue talking even if nobody is paying attention? What do you do to get their attention, or do you care? Do you ask questions? how do you handle questions from the students?

The traditional lecture style in which the students sit quietly and take notes  was named the “Banking Method” by Paulo Freire (an early guru of mine) and it is still alive and well, aided by PowerPoint – you can’t stray too far from the plan when there is a PPT for the subject of the day.

What if nobody is paying attention?

To me, that indicates profound disrespect. We’ll cover getting the students attention, another time. For that matter, we’ll talk about what they are doing instead of paying attention – primarily checking FaceBook and texting – in detail in a future blog.

General principle: A student’s question is never simply a question. it is a reality-check for you. Does the student’s question follow logically from what you just said? does it indicate that the person was paying attention or failed to comprehend something?  In an undergrad program, does the question ( and answer) fit a “generalist” frame, worth spending class time on?

never actually answer a question if you can avoid it.

never actually answer a question if you can avoid it.

never actually answer a question if you can avoid it.

It’s not about what you know, it’s about what the class learns. if the student was paying enough attention to ask a good question, repeat it for the whole class, and give it time to sink in.

Here is a way to maximize student participation in questions: Pair the students up if you need to, tell them to take a minute to discuss, and then poll the whole class for possible answers.

If you are new to teaching you sometimes need to answer questions to establish the idea that yes, you do know something about this subject; but the job is to get the whole class over the fence, not just the two or three most articulate ones….. and this is a way to engage a larger number.

If the student asks a poorly-informed question, never deliver a put-down. Never use sarcasm. ever.

Here are a few “types” of students to notice.

the squirmer

The squirmer sits in the front row of the class and is constantly raising their hand to participate. If you ask the class a question, the squirmer will blurt out the answer before the rest of the class has figured out the question. The squirmer will get to class early and show you some special thing they found which was above and beyond the assigned reading for the class.

assessment of the squirmer?

probably has studied like crazy and is desperate for recognition as to the work they have done.  BUT – disrupting the class  in a subtle way – they are preventing anybody else from answering a question; they are trying to make it a one-person class. some teachers get into the habit of stating the next lecture point as a question-that-is-not-meant-to-be-answered – are you one of those? If so, you may wish to reconsider……

variation of the squirmer: the e-squirmer. This is a person who uses email, texting and IM to ask questions out-of-class, and is disappointed that you don’t answer right away ( the idea that you may be asleep at 0300 on a Sunday morning does not seem to cross their mind). Do the whole faculty a favor, and resist the urge to respond to anything immediately. there are limits to your instant e-availability! Set limits on e-communication, and stick to them

PEARL OF WISDOM – intervention with the squirmer  take them aside and tell them ” There is no question in my mind that you are the star of this class. From now on, you are forbidden to answer any question. Instead, use your right hand to pull your earlobe three times in a row. I will wink at you to acknowledge that you know the answer, but from now on the policy will be to only call on you at the end of the little mini-discussion.”

The dreamer

This one is probably along one edge of the class, near an electrical outlet. The laptop is set up, and he is probably looking at FaceBook or checking email. He is there-but-not-there. assessment: find ways to engage this person in class. call on them by name, yes it’s an old trick from sixth grade but it reinforces the need to participate. Re-arrange the chairs so that students working in groups need to face each other and interact. Consider a clear policy as to when personal computing is okay or not. (this is tricky. If you are lecturing from PowerPoint, often the students become accustomed to having their own copy in front of them). Realize that whenever students have a smartphone in class, they are texting each other, probably about your lecture style.

For me, I walk around as I talk during lecture class and I notice what’s on the screen and whether the person is paying attention.

the kibitzer

the back row of the class will often be taken up by four or five really intelligent students who sit their with their arms folded, muttering to each other as you lecture.

yes, they are laughing, and yes, they are laughing at – you.

assessment: sometimes this is a bright subgroup of students. Each of them thinks they could be more exciting than you if only they were the teacher. Don’t take it personally. If that is the case, you can often leave them alone and they will do okay.


There will be a group of students who actually are there to clarify what they read and to put it into perspective and context. This is the group to which your lecturing should be directed. When you are planning out the lecture, close your eyes and pretend that one of these students is sitting right there, and plan as if you are speaking to that specific student.


For a beginner faculty member, it is easy to direct your teaching to the brightest students in the class; it is easy to focus on those aspects of nursing care that are sophisticated and cutting-edge which you yourself learned in graduate school. In an undergraduate program, this is always a mistake new teachers make.

Final Pearl of Wisdom

Direct your teaching to the middle of the class – they are the ones who can benefit from an in-person explanation. Force yourself not to spend too much in-class time with the top students. They will do fine without your help!


Filed under Uncategorized

taking suggestions for next blog entry

it’s the end of semester and I have been busy – so, not as many new blog entries.

I will be away on the mainland all summer, starting in two weeks, and I expect to slow down on this blog.

the last entry, on foreign nurse requirements, was surprisingly popular  – seems to still attract a lot of attention qday.

Got any requests for topics for future blogs? let me know.

I look through the “search engine terms” to get ideas – I notice that there is a lot of interest in “obsessive-compulsive disorder in nursing” and may be I will expand my previous comments on this.


Filed under Honolulu, nursing education