Tag Archives: nursing education

Ten experiences every nurse needs before graduating from nursing school

Ten experiences each student nurses needs to have before getting out of nursing school

There are two trends in nursing school today that bother me. I know that I am an opinionated curmudgeon at times, but I need to say these out loud, just in case the act of putting it out there makes them go away like magic. In reality, I know that we can’t wave a magic wand and get what we want, but – work with me on this!

The first is a nationwide trend. Every nursing school is full to the max with students and it is harder to get optimal clinical experience. We are substituting simulated experiences for the real thing. We focus on “the standard patient” as if all patients are standard when they are not.

The second is, we are losing the old “what is nursing” battle. By that I mean, there is increased emphasis on medical content. Physiology, pharmacology, surgery, etc. less emphasis on psychosocial implications. This goes hand in hand with the lack of “role socialization” in nursing.

Tip: the NCLEX tests nursing, not medicine. Every question on the NCLEX is either an Assessment, Planning, Implementation or Evaluation question. The Nurse Practice Acts define nursing according to APIE and nursing diagnosis; the “junior doctor” parts are limited to the section on Delegation. Every nursing faculty needs to ask themselves about whether they are teaching nursing or medicine, and to have a clear handle on the difference. If your school is having problems with NCLEX pass rates, it’s probably because the faculty are confused about this specific principle.

Let’s explore the above, shall we?

To begin with, I first taught on a nursing faculty fulltime in 1990. I taught maternity and pediatrics, and took students to a hospital for OBGYN that did about 1200 deliveries a year. That meant an average of one baby born per shift. Sometimes more, sometimes less. In those days I made a pact with the students. If they would be flexible about their hours the day they were in Labor and Delivery, so would I. the goal was to help them have the experience of seeing a baby born. In the three years that I supervised students in L & D clinical, every one of them did see a delivery. One time I hung around until 9 PM. That specific student got the idea of how long it actually takes to deliver a baby. the idea was to get a first hand look at the way all the theoretical stuff translates into what is done in real life.

When we try to simulate every experience, there is a tendency to only present scenarios where the ideal is portrayed, and to sanitize everything somehow.

On a related note, on day one of maternity orientation, I always asked the nurses to save me a fresh placenta or two. We would all don gloves, look at the membranes, the cotelydons, the shiny and dirty side, etc and marvel at it. I always viewed this as an important experience to have. It desensitized the student to the appearance of body tissue, helped them to visualize what we were talking about ( so much of prenatal care is designed to help grow a healthy placenta) and removed some mystery.

Nowadays, I am sure there are people who would look on horror and say “Om My God, it’s exposure to body fluids!” – well – no – not when PPE is applied. even in those days we wore gloves.

Ten. maybe more

There are ten clinical experiences you should have. I sincerely hope that every nurse gets these while still in nursing school, but if you don’t you still need to find them at some point. The advantage of having them in nursing school is, an experienced person can interpret the experience for you. Guidance from a guru is critical to draw the proper conclusions. By proper I mean, conclusion which reflect the role socialization appropriate to nursing.  without the proper guidance any of these can do a number on your head.

1) Coaching a woman through labor and seeing a baby born.
2) Giving a shot to a 2-year-old. Getting a 2-year-old to do anything!
3) Being with a person who is dying from cancer. Two parts: talking to them before hand; and being present at time of death.
4) Seeing surgery
5) Smelling cautery. Or any one of about a dozen distinctive olfactory stimuli peculiar to health care.
6) Having a conversation with a person suffering from delusions or psychosis.
7) Talking with family members of a person having a serious illness, whether it’s acute or home-based.
8) Doing CPR
9) Dealing with a drunk person.
10) Helping a person who is a member of an oppressed minority, whether it is a racial or ethnic group, a group subject to bullying, or perhaps a homeless person.
11) Giving nursing care to a person who is seriously ill but who is your own mirror image in terms of age, social level, education, family etc.

The key to each of the above is, it’s not about the actual experience per se. it’s about incorporating the interpersonal flexibility required to actually be of use to the person receiving the care, and about dealing with your own feelings and reactions. There is only one way to do CPR ( the Heart Association protocols) but it is inevitable that you will have personal thoughts go through your mind when you are doing compressions, and these need to be considered “by hand.”

special note about autopsies

I was once asked by a student how come viewing an autopsy is not something we can arrange, or why we don’t include it or promote it. At the time I thought the student ( a male of course) didn’t quite “get it” and had a sort of voyeuristic quality to his request. “What is the goal?” I asked. Let me emphasize that simply getting these experiences checked off is not the purpose.  The purpose is to develop an overall professional approach that can be generalized to all such experiences that have any aspect of threat to the self-image of the student.

If I had to name a single concept that everyone needs to grasp, it’s “this is not a game, not just a well-paying job, but a critical service offered to society by members of this profession.”  Often by being the one  person in the room who is maintaining composure during a stressful event.  You could look at the above list in that way.

For each of the things listed above, there are certain professional expectations as to how a successful nurse conducts themselves. I could write a blog on each one to detail these, but hey – that is what textbooks are for!

hint: we can develop a simulated experience to go with each of the above, but it will never substitute for the doing of the actual thing for a real person. Not ever. just about every negative experience can be reframed into something positive with proper guidance. (for example, cleaning human fecal incontinence can be viewed as distasteful because it involves feces, or else we can reframe it into helping the person feel better and clean while retaining dignity).

Nursing Diagnosis sayonara

As to the “junior doctor vs actual nurse” argument – I worry. There is a trend by which nursing schools are quietly getting away from the teaching of nursing diagnosis. What does your school do?

I have heard all kinds of rationales – “practicing nurses don’t use it” being the main one. My answer is, “practicing nursing surely do use nursing diagnosis!” though maybe they call it something else. Maybe they have it down so well they it is less obvious, but I guarantee you that no hospital can have a functioning customer service program unless somebody in the nursing service uses psychosocially-based problem-solving. Caring is a learned behavior, and nursing diagnosis is the vehicle by which we teach people how to care. You need more than just warm positive regard for the person you are serving. It’s too hit or miss otherwise.

Hold hands before crossing the street – the lost art of curriculum design

Nowadays in the shortage of nursing faculty, we are pressing into service anybody with a Master’s Degree, including nurses that took a Nurse Practitioner course and never took even one course in pedagogy, test construction, curriculum design, or anything. Such a new faculty person needs guidance in how to be a teacher.

Curriculum Implications

When ever there is a transition from one curriculum to another, or whenever you are designing a comprehensive course of study, it’s useful to think of a “crosswalk.” In the parlance of educational design, a crosswalk is a comparison of two lists. The first is the “old curriculum” and the seconds is the new. Where does a theme of nursing school appear in any given course of study? If it was there before and you are changing your curriculum, where is it now? It is a useful exercise to make a list of things the student is expected to know (we call them “outcomes”) and to actually place them somewhere along the line, in a rational sequence. For example, if a student nurse has never dealt with a normal person having a crisis, why would a curriculum expose that same student to concepts of mental illness first? The crosswalk needs to be analyzed according to how to teach psychosocial needs in a logical sequence. This is simply lost when the coursework focuses on a tour of body systems or medical diagnoses.

Bottom line

To become a fully actuated professional nurse is a lifelong process. When a nursing school teaches you how to care, they are teaching you “how to be a human” – which sounds easy. It’s something we need to think about….. If we only present the “standard case” we are focusing too much on the basic medical care, and not enough on the psychosocial.

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what did you do for your summer vacation

school begins again soon.

if you really must know, here is what I was doing all summer….

http://joeniemczura.wordpress.com/2013/08/14/preliminary-report-of-ccnepal-2013/

It was fun but I will be happy to be back in a routine.

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nobody wants to teach nursing

received a provocative link from a colleague.

see below

http://www.insidehighered.com/news/2013/07/22/nursing-schools-face-faculty-shortages#ixzz2ZnV1RCGX

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In Defense of the living, breathing professor – and patient

link to an article in the Wall Street Journal, titled “In Defense of the Living, Breathing Professor” . In brief, he is saying that there is flawed thinking when we measure college education by “output” as if we were making widgets on an assembly line.

The author makes the point that human contact is the key element of education. He’s a physics teacher.

Nursing education certainly needs to incorporate active coaching on a one-to-one level as we impart the process of patient care. Nowadays we are more likely to use simulated learning ( “Sim-Man”). We are more likely to develop sophisticated scenarios such as the Heart Association has used in ACLS classes for thirty years. This is all well and good,  but it reminds me that I  have been meaning to write something similar to my esteemed colleague from Williams College. My own essay would be titled “In Defense of the Living, Breathing Patient.”

Does this apply to clinical?

you bet it does.I do think that the faculty need to be actively involved in assessing and caring for every patient assigned to their students, particularly at the beginner level, and that faculty need to model a level of engagement that promotes the idea of how to change the plan when you go “off script.”  For this, faculty need to be experts in clinical practice.

Nursing faculty shortage?

This takes careful planning. I think we have a national infusion of new faculty who are uncertain of this role. Those of us who are older faculty members need to find the means to share what we know if we are to create the best environment.

I think I will write future blogs on the subject of technology and the human element. In the meantime, welcome back to school!

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2 of “10 tips.” – – – Mantra for New faculty. need to repeat this over and over until they “get it”

We are all in search of the eternal truths of life, and nursing education is no different.

hint: be sure to click on the hyperlinks. These show up as underlined text or sometimes as text of a different color.

If I had just one magic incantation for new  nursing faculty, it would be this one:

It’s not about what you know, it’s about what the students learn

Medically-oriented knowledge

Do you know a lot about physiology? This is the answer to a common pitfall for new faculty who are trying to decide what to focus on when choosing material for a lecture. You have just come from graduate school in nursing and you make up your mind that you will be a better teacher than your undergraduate faculty were; the students will learn more advanced concepts from you than they ever learned from somebody else.

result: you spend time lecturing on some physiological problem that doesn’t happen that much. students are left confused. they don’t know whether it was important, or not. they scratch their heads.

hint: if you are discussing some physiologic problem that you personally have not dealt with, or for which you can not give an example from your practice, it’s probably waaaay over the student’s head.

working with beginning generalists

Or else maybe you are feeling imposter syndrome and you need to reassure yourself how smart you are and that you really do belong here.  You can tell if this is happening to you because you have the uncontrollable urge to share your qualifications or to talk about the finer points of some unusual medical illness that maybe the other faculty haven’t even heard of.

hint: this is nursing school, not medical school. what does the nurse need to know about the topic at hand?

Exams by a new faculty – what do they measure?

Or maybe you are looking at the item analysis report for an exam the team just gave, for the very first time and you see that the students scored a “0.0%” on the correct answers for all your questions; you find yourself arguing that they really ought to know that answer.

hint: when nobody chooses the correct answer for a question, you really do need to consider the possibility that there was something wrong with the question, or perhaps that your teaching was not effective. This is humbling.

Truth: if the entire class scores poorly on any given exam,  it is a reflection on you, not on them. How could you have presented the material better? in the meantime, drop the question overboard without ceremony. you will do better next time.

ability to test reality

I only recently heard about a phenomenon known as the Dunning-Kruger effect.

The Dunning–Kruger effect is a cognitive bias in which unskilled individuals suffer from illusory superiority, mistakenly rating their ability much higher than average. This bias is attributed to a metacognitive inability of the unskilled to recognize their mistakes

Even though you may not heard of this by name, surely you seen it at work – I know I sure have.  As clinical faculty, one of our main jobs is to give students a dose of reality-testing strong enough so that they can develop a sense of their own limits and abilities.

The Dunning-Kruger Effect applies to you as a new faculty member. You will be evaluating not just what they students learn, but how. The same applies to evaluating your own skill in a new dimension.

Pearl of Wisdom

I guess the executive summary of this blog entry would be: when you start a teaching career, leave you r ego at the door. be humble. trust yourslef that you do belong there, but in the meantime, start thinkiing about the goal, which is to enhancestudent  learning – not to show how much you know. I will end this blog entry with The First Rule of Knowledge (according to Buddha) which is:

admit what you do not know

PS please pass this along to as many faculty and nursing students as you know and encourage them to subscribe to this blog. hey – why not subscribe yourself?????

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#1 ten tips for new nursing faculty – name tags at school

new series

Announcing a series of blog entries for nurse educators. For the next few blogs I am going to share some hands-on ways to make the class hum. Surely you know what I mean. Sometimes every one gets to a class with enthusiasm, ready to share and participate; other times the group trudges in, head down and dispirited. Forced to be there against their will. Which class room experience would you rather have?

today’s tip – name tags

Something I do at the beginning of each semester is to get a box of name tags, the pin-on kind. on the first day, there is a table at the door to the class with lots of marker pens. Instructions: “write your first name on this tag, using the whole tag; write it in letters so big that an old man can read it from across the room”  then I explain the system for collecting them at the end of the class.

was this worth writing about?

Yes, this is so simple it sounds stupid, perhaps not worth writing about. but for those who dismiss it: do you know the name of every student in your class? especially at the beginning of nursing school, the students have come from prerequisite science classes where maybe there were 300 people in a lecture hall ( happens in a lot of Universities). They become accustomed to the idea of anonymity.  There is a lot of sociological work about what happens to people when they feel they are totally anonymous….. In a work setting in health care, anonymity is never an option. start now to get people used to this.

an alternative

The University used to photograph every nursing student and keep the photos on a shared database with their names. for cost reasons we don’t do that anymore. But, with the advent of smart phones, one thing I did recently was to take each student’s picture using my own smartphone, along with the email and number. I indexed the photos in such a way that if I forgot the students name during class, I could scroll through the photos and remind myself. At the end of the semester I delete each class, but then I find I can still remember them next semester even though I have to learn sixtyfive new names and faces.

advantages:

the students will learn each other’s name. In a big classroom, don’t assume that they know each other. sometimes they only stick with a subgroup such as from their clinical site.

you grab their attention when you call each student by name in class. The students know that they can’t be anonymous during a class discussion.

if every one picks up their name tag at the beginning of each class, you can easily tell who is absent simply by looking at the leftover name tags.

If the students are wearing a name tag with LARGE LETTERS, you don’t need to  be close by to remind yourself who they are. For a male faculty in this age of political correctness, this is a good thing,  since there is a taboo about glancing down at a woman’s thorax to read their name in small letters.  the awkwardness of this can be avoided.

disadvantages

people lose the name tags.

people may protest that it isn’t “cool” – and frankly, sometimes the faculty can’t be bothered….. that is a problem. You do need to get the faculty to buy in and enforce it if the course is team taught. A box of name tags costs $20 and you can’t afford to buy a new box each week.

invariably, as the semester proceeds, people sometimes try to fool you by trading name tags with somebody else or perhaps deciding that everyone will be “Barbara” on a particular day. Actually, when that happens, I interpret it to indicate that the students are having fun.

ways to use this system

we once had a cohort in our lab class where the students seemed to form cliques that did not mix. In that lab session, there were three clinical groups and they stayed amongst themselves. nursing students need to learn to work well with others and to keep themselves fresh. We decided to put a small fish sticker (like you buy at the Drugstore for kids) and add a sticker to each name tag. When the time came to break up into groups of three, we told them to arrange themselves so each group of three was composed of one person from each of the three groups, using the fish stickers as a guide.  problem solved.

Philosophy of cliques

I have referred to this a bunch of times without clarifying why it is so important to break up cliques when they form. Generally, when the students clump together, the subgroup will include all the top students in one clump. When that happens, the lesser achieving students are deprived from working alongside them and learning from their peers. I will write a longer blog on this later – I believe that forming cliques is something that contributes to ” Nurses Eating Their Young”

We used variations of this all semester long. Whenever the class breaks into smaller groups, you can choose to direct the class as to how to compose each group.

Thes tips all come under the header of “Classroom Management” techniques – if you were teaching in third grade, you would probably take a three-credit course in this. Not so much of a priority in nursing education.

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Part 3 Nurse’s Brain – Nurses and Obsessive-Compulsive Disorder (OCD) – how is yours today?

NOTE: run your mouse over this section, and the hyperlink will show up……take the quiz!!!! the whole point of this blog is to discuss your reaction to the quiz….

True Story of my daughter when she was five

One March, a blizzard started working its way up the east coast of the USA, and in Maine we had five days to read the daily report on the front page of the local newspaper which breathlessly warned what it was going to be like by the time it got to Maine. It was the topic of conversation every day. My younger daughter was worried. we lived out in the country. In addition to the lights and fridge, we had a well with an electric pump. We expected to lose power.

To assuage her worries, the family sat down with paper and pencil over a cup of cocoa, and made a list of all the things to do to be prepared for a blizzard. Buckets of water ( to flush the toilet), flashlights, candles, wood from the woodpile, snow shovels handy, groceries stocked up. Every thing. then we checked off the list and said ” the only thing left is to make snowmen when it gets here and keep the driveway shoveled.”

It helped. the blizzard was serious, but we felt better about it. we were ready. The list was useful. the fears were greater than what the truth turned out to be. And in the meantime, our daughter got the demo of a terrific coping tool.

Thought for the day

Are we raising a new generation of nurses to have Obsessive-Compulsive Disorder?

Recent blog entries

I have written about the ways to use a Nurse’s Brain in the recent past, and also about ways to succeed at the job search as well as at work once you get the job. I gave contradictory advice as to whether nursing students should be taking ACLS or not, and I also heaped praise upon the book by Atul Gawande, The Checklist Manifesto.

It’s been clear to me for years now, that if you want to succeed in a hospital staff nurse role, you have to develop a system for keeping track of dozens (hundreds?) of small details during the course of a day, in order to be on top of what is happening. The Nurse Brain is an aide to your brain to do that without going crazy.  We have developed an entire discipline, “Informatics” to study the science of how to assist people in doing this kind of detailed work.

There is a point, however, when you have to step back and ask yourself whether you have stepped off the path of sanity and into the wilderness of doubt,  and developed Obsessive-Compulsive Disorder.

Take This Quiz.

AT a site named Psyche Central, they have a self-quiz.  I invite you to check it out – take it. you don’t have to share the results with any body.

Rational fears versus irrational fears

Naturally, there are flaws with the questions – for example, the person who built the quiz probably thought they were dealing with takers that had the irrational fear of such things as death, accidents, contracting AIDS, etc.

The truth is, in many nursing settings, for many nurses, these are entirely rational fears. We have a job that is a bit unusual in that respect. “Do you find yourself washing your ahnds every five minutes or perhaps cleaning compulsively?” – yes I sure do especially if my patient has a communicable illness…… so – I suppose it may be skewed – or maybe it is one more indicator that what I am talking about is real. You can go overboard….. or can you?

In defense of the Brain

if it is any consolation, one way to use the Nurse’s Brain is to re-assure yourself that you did do everything you set out to do – and then to fold it up and shred it at the end of the day, knowing that you do not need to worry anymore about what you left undone. We are all in search of certainty, the knowledger that we did what we could. Certainty is not exactly the same as serenity, but it gets you there…..

Hospitals face a challenge with OCD among nurses

this will be a short blog, but I leave you with one thought. after you have checked your own OCD level, look at that of the nurses you work with. If the workplace is dominated by nurses with OCD, chances are, they spend time focusing on the small details, beating each other up as a means to feel better about perfectionist behavior. I would politely say that such a work environment is out of balance, and not a healthy one.

And it’s worse if the manager has OCD

OCD is a reaction mechanism to try to control things that are essentially not able to be controlled. Yes, a nurse with OCD can be a great nurse, but what happens when such a nurse is hired to be in a leadership role? usually they are the ones who have the least ability to delegate, the least flexibility, and the least ability to inspire and lead.

what do you think? take the quiz and let us know the result ( if you are brave…). agree/ disagree?

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part 2: The Nurses “Brain” – how to bring your “A Game” to clinical

read part one first. That was among my most popular entries ever. If you are finding this useful, your fellow students probably will too – why not share it with them? It’s part of a series of blogs on the current nursing scene, especially for new nurses and nursing students. I also invite you to  subscribe!

“What we Have here, is a failure to communicate…..”

There are a few common scenarios in nursing education. These take place at clinical.

a) at the end of the clinical day the instructor is making rounds after the students have left, and one staff nurse says “your student in rm 438 did not give a bath, did not report the vital signs, and omitted a med that was due at noon” (this always puts the faculty on the defensive, in case you wanna know)

b) the teacher and the student are lined up at the med cart about to give a heart pill, and the student did not check the Apical Pulse or take the Blood Pressure. Or maybe it’s a stool softener and the student has no idea when the last time the patient moved their bowels. or maybe it’s lasix and the student doesn’t know what the K+ was.

c) the student takes report from the night nurse, but doesn’t write anything down and can’t recall what was said when the faculty asks what the night nurse had to say about the patient.

I can think of more; but what I want you to ask yourself right now is, have any of them happened to you?

The reaction to all of the above, is to pass the feedback along to the student, and maybe to put the student on a written warning, which is logical. After all, we’re about doing our best, here. If the student gets enough written warnings, they learn to be afraid of making a mistake, (which is good); but they also learn to dislike clinical, (which is bad. clinical is the reason we are here). And the faculty wonders why this happens over and over again…….  a new faculty person is also on a learning curve, and when you are new at teaching, y0u may not have the tools to develop a better approach. It’s easy to blame the students….

Pro-Active? or Re-Active?

Simply dumping on the student is usually a sign of a faculty member who did not see the value of teaching organizational skills to their crew. It’s the easy way out – a way for the faculty to shift blame. It’s Re-active – closing the barn door after the horse has left. Both the student and the faculty will benefit from a pro-active approach – oh, and so will the patient :-)

You may find this difficult to believe, but to use a Road Map, also known as the Nurses Brain, is a pro-active tool in preventing all of these things from occurring. There is no situation so chaotic that a Brain can’t bring some order when it is applied.

Part One dealt with how to set up a Brain.

I got a terrific reply to Part One  from Dan Keller, a nurse who has a Blog Site Titled Nurses Get it Done. Dan was very humble about his site, but I was happy to find it. Go there, and you can find more examples of a Nurse’s Brain. He also has info about an iPhone app that can be used to keep track of all the little pile of details that a nurse has to deal with.

So – how to become pro-active vs Re-active?

For me as a faculty, I require that the student bring a Road Map to clinical and show it at the beginning of the clinical day. Every time I speak with that student during the day, we pull it out and go over it. Every time a staff nurse gives report, the student also writes down every tidbit of data that has been shared, and the student has to determine whether a followup response is required.

I got another email from a nurse who said she wants to make sure the student can name what’s going on with their patient “and that’s the most important.”  Fair enough. She probably works with seniors; and also,  when you make a Road Map every day, you can add reminders to yourself to schedule an actual time to physically assess the most important feautures of your patient’s illness event. In addition to the Road Map, we also require a Concept Map, an eight-column medication form etc – if I made it sound like we didn’t, or that I never bring up the more sophisticated concepts of patho, don’t worry – we do those things.  The time to start using a Brain is Fundamentals – from the beginning of hospital practice.

Accountability

One of the mantras is: ” we don’t have to do every single thing we planned out for the Road Map, but if we can’t, our responsibility is to tell the staff nurse with sufficient time so that they can do it before it’s too late”

If the whole crew is using a road map, it allows the clinical groups to create synergy, and help each other by scheduling some tasks for the larger group – such as doing incontinence care for a 400-lb helpless patient, for example, which would require more than just one person. I worked at a 400-bed hospital in Bangor, Maine, where the nursing crew routinely delivered care for  patients with life-threatening morbid obesity – that group of nurses were a marvel of teamwork. This eliminates a lot of mini-crisis from the day.

Buying the morning paper?

The next thing that can happen with a well-planned Road Map is effective chaining of tasks. Now, women are much better at chaining tasks than guys are ( hate to sound sexist and I don’t know why this is the case, but I think it’s true). True story: if I was going to get the morning paper from the corner store, I would go and get it. But, if I mentioned to  my wife I was going down the street for that purpose,  she would say “Oh, and we also need toilet paper and would you get some bread and milk too?”  My wife was also a nurse. Nurses become excellent at “chaining” tasks.

Chaining….

an example of chaining for the Road Map would take place after you observed that it was an hour after breakfast and  your patient was incontinent of stool.  Obviously, you are going to help them with personal hygiene; so you might as well do their whole bath at that time, and you will bring in the supplies to do a sacral dressing change if they have a sacral wound, and you can also check their heels at the same time, do range-of-motion and repositionthem. six tasks with just one trip into the room.

The Checklist Manifesto

We are on a quest for excellence in nursing, not just personal excellence but excellent patient outcomes in team care. And I can’t speak highly enough of the books by Atul Gawande, MD.   His book, the Checklist Manifesto, is about the ways that teams improve, and he has lots of practical examples and a great way to express how to approach the idea of improving your practice day-to-day.

I can’t really add much beyond what the reviews have already said, but here is a start, from Amazon.

Amazon Exclusive: Malcolm Gladwell Reviews The Checklist Manifesto
Malcolm Gladwell was named one of TIME magazine’s 100 Most Influential People of 2005. He is most recently the author of What the Dog Saw (a collection of his writing from The New Yorker) as well as the New York Times bestsellers Outliers, The Tipping Point, and Blink. Read his exclusive Amazon guest review of The Checklist Manifesto:

Over the past decade, through his writing in The New Yorker magazine and his books Complications and Better, Atul Gawande has made a name for himself as a writer of exquisitely crafted meditations on the problems and challenges of modern medicine. His latest book, The Checklist Manifesto, begins on familiar ground, with his experiences as a surgeon. But before long it becomes clear that he is really interested in a problem that afflicts virtually every aspect of the modern world–and that is how professionals deal with the increasing complexity of their responsibilities. It has been years since I read a book so powerful and so thought-provoking.

Gawande begins by making a distinction between errors of ignorance (mistakes we make because we don’t know enough), and errors of ineptitude (mistakes we made because we don’t make proper use of what we know). Failure in the modern world, he writes, is really about the second of these errors, and he walks us through a series of examples from medicine showing how the routine tasks of surgeons have now become so incredibly complicated that mistakes of one kind or another are virtually inevitable: it’s just too easy for an otherwise competent doctor to miss a step, or forget to ask a key question or, in the stress and pressure of the moment, to fail to plan properly for every eventuality. Gawande then visits with pilots and the people who build skyscrapers and comes back with a solution. Experts need checklists–literally–written guides that walk them through the key steps in any complex procedure. In the last section of the book, Gawande shows how his research team has taken this idea, developed a safe surgery checklist, and applied it around the world, with staggering success.

The danger, in a review as short as this, is that it makes Gawande’s book seem narrow in focus or prosaic in its conclusions. It is neither. Gawande is a gorgeous writer and storyteller, and the aims of this book are ambitious. Gawande thinks that the modern world requires us to revisit what we mean by expertise: that experts need help, and that progress depends on experts having the humility to concede that they need help. –Malcolm Gladwell

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How to avoid the Nursing Work Culture From Hell

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Culture at the workplace?

A workplace becomes a surrogate family for the people who spend time there. When people spend so much time together, the personalities come out. A group will adopt a set of informal rules that guide each day. This becomes “workplace culture.”

If you have been a nurse for any length of time, you develop a sixth sense for this. The minute you walk on to the patient care area, you get a vibe of what it’s like there.  It may be calm and peaceful, it may be chaos, it can be happy or tense. It can be this way independently of how much nursing care the patients require. When you interview for a nursing job, be advised: the best managers know about workplace culture, and they are looking to add staff who will value it and honor it. A theme of this blog has been to encourage new nurses to live up to their caring potential, and it includes caring for those around them as well as for the patients.

Urban Community Hospital – a “war story”

My first nursing job was not a place for teamwork. It was an “urban community hospital”  and chronically understaffed. Each shift was a contest to see whether you could get through all the work yourself, and the assignment was heavy. It was a trauma ward, lots of gunshot wounds and stabbings and victims of beatings, along with a population of heroin addicts and homeless persons. Lots of crime victims. The staff consisted of a head nurse who had worked there since the dawn of time, and each spring there was a fresh crop of new graduate RNs. The hospital would hire a batch of new grads all at once, they would stay a year, then leave once they got “the golden year” of hospital experience. Or at least they were planning to leave then; most left my particular unit before hand, chewed up by the system of unsupportive coworkers. The crew of nurses aides were all older than the young RNs.

Walking Rounds

We did “walking rounds” there, change-of-shift report consisted of a procession of sorts, all the nurses in a group  following the kardex from bed to bed like it was the Bible at the beginning of Mass. The circus was led by the head nurse, same age as my mother. She generally arrived each morning with an attitude, and would heavily criticise the night nurse, pouncing on any inconsistency she found between the way the patient looked and what was written in the kardex; or how the story was presented.  Very theatrical. As report was read, she would examine each patient (“you said the IV was NS w 40 of K, why is it I see a bag of LR hanging?”) This included getting on her hands and knees to look under the bed, on occasion, as well as barbed sarcasm. Every day.  One day she chased a rat out of the ward, to the cheers of the rest of us…. but that is a whole nother story ( it was a very large and well fed rat). Yes, she was teaching us how to have standards and to follow them; but nowadays we would call her approach “horizontal violence’ or “verbal abuse” or “eating the young.”  That was the way it was in that time and place.

These days there is a national movement toward something called “Magnet Culture” – hopefully to eradicate that sort of approach. UPDATE: a former student emailed me after reading this, to alert me to some excellent work published by Sigma Theta Tau about Bullying in the Nursing Workplace.

New RN working nights

I was on eight-hour shifts, a day night rotation and soon found myself working nights about eighty percent of the time – the only time I was on days was on the head nurse’s weekend off.  The day I passed my Boards I was Charge RN whenever I showed up from then on. That was how I spent my first year as an RN. Since I was on nights so much, it meant that I got to be the person going through the gauntlet every morning. And yes, I did well at it – better than the others. In those days I could be just as sarcastic and unforgiving as others. I would spit it right back at the head nurse, to the astonishment of other first-year RNs on the crew.

I no longer treat others that way.

The usual night staffing was two RNs for up to thirty patients, and even then, I went out of my way to help the other RN be ready, which was appreciated. I promised myself I would never be the kind of nurse manager  that I was now working for, and that if I ever had anything to do with it, I would be kind and respectful.

In other words, it was the Work Culture from Hell. Got the picture? I can go on and on – you got me started, but like a bad dream, I need to wake up and remember that this degree of dysfunction is not the way to go through life. Let’s focus on positive ways to interact, here.

Teaching workgroup culture. learn it and live it.

What I do now is to incorporate healthy work behaviors into nursing school. Nursing school is not simply to learn about patient care; it’s to learn the way a professional person acts and thinks. Sometimes in the Fundamentals lab, a student acts as though the only thing they are there to accomplish  is to learn how to perform a specific skill according to the checklist. They don’t care whether others also learn, and don’t help their classmates or spend time coaching somebody slower to grasp the concept. Somehow there is a subset of students who think it’s okay to be a jerk to those around them while they focus on their own learning needs. This may work for Jack Sparrow, but will not lead to success in a hospital workplace.

This tells me that such a student has a learning opportunity.  Focusing on yourself is not the way to go through life. You are missing a major part of the ride.

(Note: a few years back I developed a one-page handout for how to act in the nursing school lab which I will send to anybody who emails me and asks for it)

How to Succeed as a team

Want to develop the habits of a helpful work group culture? here are some ideas. They are not a “Code” – more like Guidelines.

In both lab and clinical: Your work is not finished until the work of everybody is finished. Nobody sits down until everybody is able to sit down. If one person is getting swamped, we pitch in and help them. In the lab, it’s the students and faculty together, who tidy up and make the lab ready for the next group of students. Don’t rely on somebody else to clean up after you.

In the clinical setting: learn about  each other’s patients. Depending on how morning report is handled, this can be a challenge. If it’s a group report that’s easy; but if it is nurse-to-nurse report, you have to go out of your way to do this.  Find a way to check in with the other staff nurses (or the other students) after an hour or so.

Nobody lifts or transfers any patient by themselves.  There is a strong evidence-base out there regarding nurses and prevention of back injuries, so we have an important reason for this. Some wards have many “heavy” patients, and this attitude makes a big difference. But it’s also a chance to create and strengthen relationships among the staff.

say thank you. this goes a long way. there’s an old saying that “People may forget what you did or said but they won’t forget how you made them feel.” think about it.

use names. there is a parade of people through every hospital area every day. Learn who they are, and use their name in conversation.  You don’t have to go to Happy Hour with them or learn their kids’ names, but why not humanize the workplace? this includes housekeeping, the docs – everyone.

name tags. Ever been in a college class where the professor never learned your name, even by the end of the semester?  At my nursing school, we teach the same course to a different cohort each semester, there are fiftysix or sixty new names to learn. On the first day I always set up a system of using name tags, keeping them at the lab. The students collect at the end of each session. We call each of the students by name. They are not allowed to melt into the woodwork, which is often a surprise for the students.

just like a basketball team
Huddle. this picture was taken in Nepal, but any of my students will recognize this gesture. When I wave my hand at waist  level, they know that I want them to approach. I never have to raise my voice when calling them over. (and yes, they know i will not bite…) At lab and clinical practice,  I call a huddle every now and again. soon the students learn to call their own huddles without me.  Communication is a big part of teamwork. We use the time to share and to plan out our work and get ideas.

The Bottom Line about workgroups

The fact is, we all have a choice to create a healthy work culture, or not. which will you choose?

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Especially for the older nursing student – it’s not about what you know

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Nowadays nursing is a popular choice for older students, whether it’s a person who already has a college degree (and is going for Master’s Entry into Nursing, or MEPN), or an LPN going back to get the degree, or somebody who needs to change careers.

Nursing school is a shock to the system

Regardless of how you got to nursing school, you find yourself back in college, back on the treadmill of studying, exams, seminars, group projects – everything. It’s a shock and a transition. For many, the shock is eased by the fact that you needed to take prerequisite courses before you finally got on the bus through nursing school, and this served to get you back into Study Mode. But it is still a shock as you learn what it is that nurses do.

through it all, there is something not to say.

“I already know everything I need to know, I am simply here to get the credential, sit for the NCLEX, and get a job. I don’t want to hear about all this theory. Just tell me what I need to do to pass the exam.”

(yes, I have heard actual students say those exact words.)

I would be the first to admit that getting a job is an okay motivation for choosing nursing, though it takes more cleverness right now than it did a year or two ago ( and yes, the job market will improve in a year or two, by the time you graduate). But if you repeat this statement in front of a faculty member, don’t be surprised if they raise an eyebrow… or two. Usually the response will be “Oh Really?” but that is not what the faculty member is thinking…….

What the faculty knows, that you don’t know

Here is why. Nurses are not paid for what they do, nurses are paid for how they think. This is such an important motto, it ought to be a tattoo (which is of course, the best way for The Youth of Today to study it).  Oh yes, we are teaching you how to insert a foley catheter, how to prepare a medication, how to start an IV, and a pile of other skills. But the skills in and of themselves do not compose the nurse. Don’t get me wrong – you need to be excellent at those skills and more. But, you need to learn how to think about patients in a wholistic manner, and also learn when not to do the skill, or when & how to change the way you do it to fit a given situation. this is the thinking part. Assessment-Plan-Intervene-Evaluate. A nurse is not a Junior Doctor; no matter how much we teach you about medicine that is only part of the nurse’s role.

for the older student

It’s possible that your faculty member may not be familiar with the term “Role Socialization” – but that doesn’t mean you can ignore this concept. Some people look at it and focus on the socialization part – thinking that maybe we mean you should be friends with your classmates. No, that is not even remotely what it means. Role socialization is the way a sociologist would describe the process of becoming a Nurse with a capital N.

Ask Yourself: How would a real nurse deal with whatever situation you are now facing?

The flip side of the coin

Here is a hint: if you ever want to impress your faculty member, ask them “How am I doing with role socialization?” and see what they say. They will most likely be impressed at the sophistication with which you are approaching the work.

If you are having difficulty getting it, the lack of role socialization will show up in your work. When you do patient care, you will miss things that you shouldn’t, and people will give you negative feedback about your “priority setting.” Or else, “lack of caring behavior” – which is of course, a dagger to your heart. A nurse’s number one job is to “care.” – we’ll go into that at some future date.

One solution? just do a websearch on the term.  You will find that there is a whole other universe out there among nursing scholars. The process of role socialization, and it’s success or failure, is a strong current in nursing education. Most of the links to it are to be found in scholarly journals. Looking for a research project?

One small Jedi mind-trick that real nurses use

Here is one tip: if a patient ever asks you a question, resist the urge to give them the answer. Always continue the dialogue by asking a followup question to clarify what ever they just said.

Boys vs Girls

I have two daughters. My wife and I, being children of the sixties, thought we would raise them in a gender-neutral way. Yes, we taught them to enjoy sports and boisterous play, such as throwing a football and go camping, and (later) to drive a stick. I built them a sandbox and got them a toy dump truck and a toy back hoe. But, even without our prompting, the two young ladies would spend time playing with dolls, doing hairplay with each other, and the like. To have kids is a fascinating experience in how girls learn to be girls and boys learn to be boys. Gender roles. the best example of socialization. Hey, I didn’t create the system, I simply bow to the fact that it exists.

Just for Men

Now, for the male student:

There are special challenges in role socialization for men who enter nursing. My best advice is to find the book “You Just Don’t Understand: Women and Men in Conversation” by Deb Tannen. Yes, it was published twenty years ago.  But it is still a classic. It’s a guide to clear communication when gender roles are different. It’s kind of book you can pick up and read from randomly yet you still will get something out of it. And on Amazon, you can get a copy for less than a dollar, plus shipping and handling.

Whenever I have a male student who is having trouble adjusting to nursing school, I lend them this book. Right now, I have no copies left…… hmmmmmm…..

Just one excerpt:

JUDGMENTS ABOUT WHY PEOPLE TALK AND DON’T TALK.

“For girls, talk is the glue that holds relationships together. Boys’ relationships are held together primarily by activities: doing things together, or talking about activities such as sports or, later, politics.” (pg. 85)

“Women and men are inclined to understand each other in terms of their own styles because we assume we all live in the same world. [A] young man in [Thomas Fox’ college] writing class noticed that his female peers refused to speak with authority. He imagined the reason to be that they feared being wrong. For him, the point was knowledge, a matter of individual ability. It did not occur to him that what they feared was not being wrong, but being offensive. For them, the point was connection: their relation to the group.” (pg. 179)

If that hasn’t whetted your appetite, I don’t know what will…… remember, it’s not about what you know, but how you think….

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