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.

“Chummy” and nursing. a delicious archetype!

Call The Midwife!

be sure to click on the hyperlinks!

Yesterday was episode three of season one, here in Hawaii. I gather that my friends in U.K. and Oz saw this series last winter. And it has also been thoroughly reviewed. In that respect, this is like dating your best friend’s girlfriend – you feel torn between wanting to know what they thought on the one hand, and wanting to experience things yourself  with no forewarning.

My own bias?

I am person who hates most medical shows. If they don’t get the medical details just right, or if they do not show the emotional involvement of the nurses, or (worst of all) if they don’t show the nurses as full professionals with a practice of their own, I find myself turning the channel. trash.

Anyway, Call The Midwife is excellent. The portrayal of nurses is exquisite. A balance between the skill and what the nursing professors would call “caring.”

Chummy.

we all know people like Chummy. Imprisoned, I suppose, by the realization that she will never be captain of the cheerleaders. Her biggest obstacle is herself. I have several women in my life like Chummy, and I would not trade them for anything.

The setting is a convent in the East End of London during the post-war baby boom years, and there is a wonderful group of older female actors who portray the nuns. The convent does double-duty as the dorm for the younger nurse-midwives, and that is where the main character comes in.  But there is also – “Chummy.”Maureen Ryan, The reviewer for Huffington Post, wrote:

 Jenny Agutter provides “Call the Midwife” with a solid center as the head of the order of nuns with whom the midwives live and work, and several other razor-sharp character actors fill out other roles extremely well, but Miranda Hart, who plays Chummy, walks off with the show. By the time the sixth episode rolled around, the fate of her tentative romance with a working-class policeman made me alternately joyful and tearful, never mind all those babies or Nurse Lee. Chummy’s nervousness, her inherent kindness, her fear of upsetting her upper-class mother and the dawning realization that someone could actually love her are all depicted with delightful skill, sweetness and humor. A second series of “Call the Midwife” has been ordered, and if Chummy’s not part of it, I may stage a public protest.

I have had Chummy in my class. about a dozen times.

Oh no, that does not mean that I taught midwifery in the 1950s. That does mean that I have been privileged to see the personal growth of  certain young women who were previously sheltered from the world. Let me tell you about one such.

I will call her Barbara. Barbara was overweight and very near-sighted, shy and not athletic. At the University level, Barbara was taking classes alongside other students who had been cheerleaders in high school, or airline stewardesses,  or captain of their volleyball team.  Sometimes when I assess these latter type of students, it becomes clear that everyone gives them a bit more slack than they ought to have, simply because they have better social skills and are more outgoing. YAVIS syndrome is alive and well. Compared to these other students, Barbara was not an attention seeker.  Probably did not expect attention. Probably the kind of kid that was teased in junior high school.

Barbara at lab

Each student needed to be able to demonstrate various sterile procedures. Barbara’s hands were chubby, and it took five long minutes for her to don the sterile gloves. I took her aside and said “I have big hands too. When you have big hands, don’t rely on the gloves in the kit. always carry your own sterile pair in a size that you can don quickly.”

I always used to go to coffee at the same time as the whole clinical group, and I emphasize team bonding.  But it was at the University cafeteria that I noticed something. I was eating lunch while the students happened to be having a study session nearby. Every time there was a question, Barbara had the answer, and it was invariably correct.  She was a resource for her whole group, and they knew it.

And so I made my assessment of this student. I think her nearsightedness contributed to her lack of interest in sports.  Maybe she did not have the kind of social life growing up that her peers had as members of the cheerleading squad; but –  if it was a question of personal effort, hard work and study, Barbara was going to show them a thing or two.

Which was exactly what she did. When Barbara came to me and asked for a letter of reference for a prestigious summer internship at the biggest hospital in town, it was time for “payback.”  And what exactly did I do for “payback?” I wrote:

“Barbara is a bit shy at times but do not underestimate the effort or time that this person devotes to studying nursing.  She is a resource to her group and is very helpful in sharing her knowledge. She will work hard and will outshine the more glamorous students in her peer group. She will be a positive addition to any workgroup she joins.”

In other words, not just the stock letter of reference. She got the internship, and the rest is history. To this day she still does not know what I wrote in that letter. And the best part of the story is, I saw her not too long ago and she is still a staff nurse at that hospital, she loves her job, and seems to love her life. For me, the privilege comes when I realize that I got to be a part of her journey into becoming a professional person. I have had many other such students.

Back to Chummy

I like to think that nursing, as a profession, rewards skill and study, and is more than just a glorified charm school. That’s why I think Chummy is so intriguing.  I am predicting that Chummy will also learn and grow over the course of the series.

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!

Nurse Burnout, adrenaline junkies, and secondary stress, part deux

Q: What kind of bird are – you?

note; the underlined words or phrases are hyperlinks to related background material. be sure to to click on these.  especially the one related to my book about Nepal.

Burnout happens.

Got a lot of responses to my last blog posting about Burnout, Marlene Kramer and stress. It got mentioned in the AJN blogroll of nursing blogs which is titled “Off the Charts. At that location, they keep a list of blogs by nurses. Some are quite good.

The editor there called me “peripatetic” –  not a word I use every day. Moi? Come to think of it, I don’t spend a lot of  time trying to describe myself.  The words that come to mind are handsome, witty, charming, emotionally available, and compassionate.   :-)   and of course, humble!

Urban Dictionary

so naturally I went to the Urban Dictionary. For those of you in search of eternal youth, this is a terrific site. I would have never learned the meaning of “4-20 friendly” for example, if I had not used that resource. And of course, the place includes current commentary on issues of the day, such as this gem.  (Like the vast majority of Americans I don’t think we should elect male legislators who think they are the only ones qualified to tell women what to do with their bodies. I have spent too much time with too many crime victims to laugh at their expense.)

Peripatetic

1) The act of, relating to, or given to walking about;

2) Moving or traveling from place to place to freekin place;

3) Snooking around touching every damned thing around;

4) Cant sit still or settle down; and

5) Constantly, without rest, surveying, reconing, and otherwise annoying the hell out of everyone by any of the above actions.

Okay, well – I don’t have just one theme for this blog. I get up and think new thoughts every day. Or try to.

Today’s thought about Burnout, Secondary Stress, OCD in nursing, codependence in nursing,  and self-care in nursing

In the past blog, I reviewed Marlene Kramer’s four stages of burnout, and I focused on assessment of yourself and others. I didn’t really get into detail about some of the other things I think can help you if you are having problems with this.

Riding the Dragon

Riding the Dragon is a book by Bob Wicks, a professor at Loyola College in Maryland.  It’s about developing resilience in every day life despite uncertainty. Pretty simple wording that you could use to meditate upon, I suppose.  My two cents? when you are health care professional, sometimes your work calls you to deal with a darned big dragon!

He’s written a bunch of other books.  I met him and heard him speak when he visited the Catholic Campus Center of the University of Hawaii.  I had the opportunity to speak with him afterwards, and was delighted to receive a copy of one of his other books in the mail two weeks later. This one was titled Overcoming Secondary Stress in Medical and Nursing Practice: A Guide to Professional Resilience and Personal Well-Being.

My review of this book:

In my experience as a critical care nurse and also as a hospital manager and  teacher of nursing, I have dealt with issues of secondary stress for many years
and I have seen many victims of this problem. And so, I stay abreast of this issue.On Page 5 of the book, the author says:”it’s a ‘one-sitting book’ designed to distill current clinical papers and research; provide proper guidelines to avoid and/or limit unnecessary distress; strengthen
the inner life of physicians, nurses and allied health personnel; and offer recommendations for further reading on the topic. If nothing else, its goal is
to raise awareness that secondary stress is a danger..”and I think this nifty little tome fills every one of these these goals and more. In a survey  book, Dr. Wicks has managed to distill the best suggestions, on a very practical level, into something that’s readable and deceptively simple. I say deceptive, because he has a way of describing the profound thoughts of stress, death,
burnout, and spirituality into an engaging style.It is readable and has many anecdotes to which a clinician will relate. He makes excellent use of summarized bullet points, and checklist style formats to present ideas. I found myself thinking of all the people who need this as a christmas present.

in short: highly recommended!

There are gradations of burnout.

I gave my copy of the secondary stress book to one of my best students, who is a perfectionist and highly “driven.”

The phrase “burnout” gets thrown around a lot and can lose it’s meaning. Sometimes a person simply needs to talk with a coworker for a couple of hours away from work; other times they need a two-week vacation; but in extreme cases the person gets a glimpse of the horror that life can be for some of the people we meet, and goes into a state of full existential angst.  we can all benefit by creating a work environment that sorts through these issues.

Perfectionism as a related problem or symptom

I do think there are nurses who bring an insidious type of emotional baggage with them, who are more at risk of the total-despair variety of burnout. These are the ones who are needy about proving their worth by being excellent caregivers, but they get it mixed in with caretaking. Also known as co-dependent, experiencing co-dependency. Manifested also by perfectionism and OCD on the job.  For these persons there are a couple of really good books. One is an oldy-but-goodie “I’m dying to Take Care of You: Nurses and CoDependence.  The other is Codependent No More: How to Stop Controlling Others and Start Caring for Yourself.

Work Environment

a final point: the books above mainly deal with how to identify stress and burnout within yourself but do not really go into the management skills and sensitivity needed to create a supportive work environment.  If you have a manager who tries to suppress the staff’s ability to deal with stress collectively, you need a new manager. Honesty is a key to effective problemsolving.

Let’s be realistic: if you deal with trauma and sadness all day at work, you need help from those around you. period. If  the team is one which gives you the message that you are on your own or that somehow it’s your fault,  your stress will be magnified.

#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.

Part 4 – the Nurse’s Brain – joining the borg!

Nurse Brain

There were three parts to the discussion about the Nurse’s Brain so far, and buried in the discussion after one of the entries was a question from an experienced nurse:

Joe,  I do like your brain and it looks like a good way to teach students. However, we have a ten minute overview report followed by bedside report, then it is go go go. Do you have a preprinted template your new nurses can just fill in? I’m not sure when a floor nurse would have time to make a detailed outline for the day.

That was  a great question which deserves to be addressed in a separate blog altogether. As I have said, a brain is a way to organize data, and if your happen to be at a hospital which has a good informatics system, there must be a way to set this up so that much of the stuff gets a nurse-friendly printout. Any number of templates will do…. in my blogroll is a site where you can find a collection of such things.

Answer – join the “borg!”

In the meantime, here is my answer:

One option is for the nurses to get there a bit early and scout these things out.

But here is another way to use it: In the 1980s I was nurse-manager of an ICU/CCU in a community hospital in rural Maine. At that place, all the nurses used a brain, it was a four bed unit with a lot of CCU ( this was in the olden days,  prior to TPA and the modern era of thrombolysis, that tells you how old I am….). The team there had adopted a twist to the system (prior to the time I ever got there) which was very helpful.

One of the duties of the off going nurse was to construct a nurse’s brain for the upcoming shift of next nurse, one for each patient. Obviously it would be subject to change, but it was a good way to start. It consisted of a handwritten summary of assessments, labs, IVs, treatments, etc  and it was used along with the Kardex and chart, during report.

When the system worked (most of the time) it was terrific. (of course, there were times when the plan changed dramatically the next time somebody went into the room, but that is another story…)

You might consider adopting some system such as this. It’s way to get the staff involved into the subject of what we nowadays refer to as “handoffs” and accountability.

Oh, and by the way….

Some people will be scratching their head, asking “What is the borg?”

Any fan of Star Trek will tell you. There was a planet in Star Trek where every person was hooked directly into the main computer so that they completely lost the ability to have an individual thought, but on the other hand, each person shared the collective wisdom of a billion humanoids…..

The end result of using a Nurses Brain is effective teamwork and preparation. Here on planet earth there are different models of achievement. If you can adopt a Nurse’s Brain, you will be just like the person in this video. trust me!

Myths about becoming a nurse practitioner – things to consider about grad school in nursing

If this were a bookstore, you would read the back of the book-decide to buy. Find this on Amazon at https://goo.gl/PGTW30

 

UPDATE:  as of February 3rd, 2015, this entry has 38,633 (thirtyeight thousand, six hundred and thirty three) separate views. It’s the single most popular blog entry I have written. Please feel free to add your feedback and comments. 

UPDATE #2 My book, The Sacrament of the Goddess, was published in April 2014 in USA.  Click here to see reviews on Amazon and order a copy. see the cover on the left, below. People  in USA think of Everest when they think of Nepal. Or maybe the earthquake of April 2015. Right now, the political situation in Nepal is precarious; and one aspect of working in a Low Income Country is the feeling of being out on a limb. My book explores the peculiar terror of being a neutral medical volunteer when everyone else is choosing sides. It’s a fast-paced pageturner! The book has nothing to do with APRNs, but might give you some insight as to why any body would ever want to be a nurse…. why not buy it and become one of the cool people? 

related link about paying for NP education, click here!

Disclaimer: I myself went to grad school fairly early in my career – after just one year as an RN. In those days (the 1970s) the federal government supported nursing education with generous grants and stipends which we knew would not last forever. I did not incur any debt for grad school, whatsoever. sweet!  I continued to work as an RN after grad school, and the MS credential surely came in handy when I finally needed to have it. So – I am in favor of graduate education.

Buzzwords. The Trend Du Jour.

Advanced Practice Nursing is a big buzzword nowadays and we are using the idea of it to attract people to the nursing profession. Throughout the USA there is a proliferation of “three-year’s wonder” programs, the idea being that the student does an entire nursing program the first year, then takes NCLEX, then spend two more years getting their MSN and NP while they work part-time as an RN. It’s particularly attractive during the down economy we are experiencing, because there are plenty of people out there with prior BS degrees who are looking for a fulfilling job. It is oh-so-seductive to think they can gain the RN skill in just one year.

Okay, so it’s a wave – lots of schools and universities are offering these programs. there are plenty of stats to provide a rationale for the career track we are inventing.

The aging of the population

The lack of Medical Doctors to provide primary care

the overall need for RNs to replace the RNs in the baby boom who will be retiring soon.

etc etc etc

I am not disputing those trends, but I am bemoaning some things that seem to be getting lost along the way.

Myth One – no need to learn basic personal care

To begin with, role socialization into nursing goes out the window when the time is compressed. Many of the persons who come from these programs seem to me to be unaware of how nurses work as a team, how nurses work in a hospital, and how to do any kind of personal care for a sick person. In other words, such things as cleaning up “fecal incontinence.”  When this comes up in conversation, they say “oh, well, I am going to be a nurse practitioner and I will be in an independent practice, I don’t need to learn those things.”

Oh Really?

My retort would be: If You are hoping to get a part-time nursing job to put yourself through school while you get the next two years of grad school under your belt, you will be judged according to the standard of the nurses around you, not to the other standard. It is extremely unlikely that you will be getting anything other than a staff nurse job while you work during school. 

also, don’t discount what a staff nurse learns. accountability and integrity are a big piece of the socialization process. A staff nurse in a labor-intensive setting like a hospital, gets daily role modeling from the older nurses. daily mentoring. any new nurse needs to develop trust with those already in the setting, and people will trust you more if you aren’t afraid to get your (gloved) hands dirty.

Think about this: if a patient has been incontinent of feces, no real nurse ever just lets them lay there. Never ever. You may not have to clean them yourself, but you do need to know how. Being clean is a critical element in the dignity of human beings. a very simple precept, really….. and if you as a student disrespect this, you will not gain the trust of the nurses around you.

Myth Two – independent practice

The next myth for Advanced Practice is that “I will be in an independent practice and I am not going to need to learn to work in the kind of subservient hierarchy that a traditional staff nurse needs to navigate through”

If that is truly the case, you will need to borrow money to rent office space, hire a billing agency, advertise to the community, all those things just like you were opening up a furniture store. Ask yourself if you have the business skills to do it, or to get a loan. There are some great resources out there, I particularly recommend one book by Carolyn Buppert; but – is that what you want to do? Most Medical Doctors gave that up twenty years ago, the hassle of “hanging out a shingle” was way too much. We are training you to provide population-based care, which means many of you will be making frequent rounds in a Long Term Care Facility, as part of a group practice. The retired frail elderly population of USA is burgeoning, right? your job will consist of freeing up time for the doc you work with so they can focus more on the technical side.

The small population of ARNPs who will be doing more acute care will be drawn from among those nurses who went the hospital- nursing route and solidified their skills before they enrolled in NP school.

let’s reserve the topic of subservience for some future blog, shall we?

Myth Three

I will be making a lot more money than a staff nurse

In many states the recertification requirement for any ARNP is 40 to 80 hours per year. If you maintain dual-certification, you may have more. This works out to ten working days per year where you are in classes (or being online). When you are in class, you are not seeing patients, and your income is affected. You will also have to pay higher malpractice costs. If you are in a family specialty, you will have many patients who don’t have insurance.  All these things detract from the bottom line.

Myth Four

If it doesn’t work out, I can always fall back on a job as a faculty member somewhere.

Yes, we do have a shortage of nursing faculty. and the minimal requirement to teach is a Master’s Degree. This is one that puzzles me.  For years now there has been such emphasis on going the NP route, that very few nurses enroll in an education track for graduate school. The result? a shortage of faculty, now being filled by recruiting from among those Master’s Prepared nurses who are unsatisfied with an NP job, and who get hired to teach.

There is a problem with this. A converted-over NP with a MS degree does not automatically have the clinical knowledge base to teach in an inpatient clinical setting; and they also don’t have any course work in pedagogy, the science of teaching, how to lecture, how to construct a valid exam, none of the things an educator needs to know in order to be effective.

So far this trend has been under the radar. Any school of nursing where the administration is addressing this, will be ahead of the game.

Myth Five “I can work as an RN after the first year, and use that money to pay for the second and third years, so it’s really not so expensive after all!”  go to my latest blog entry to explore this one. Plan carefully.

Got it off my chest!

So, what you have just read was a “rant” –  the kind of complaining I always dislike. If I were to stand up at a professional meeting,  I am sure there would be  a pregnant pause when I was done. People would look around the room, and then some sweet and wise person would bravely ask And what do you propose that we do about this?

My answer would be:

for the student: realize that you are entering a profession with a long history of service and where you will learn from all those around you in any setting you enter. The more responsibility you are given, the more direct (and sometimes brutal) the feedback will be.

study the idea of role socialization. don’t let it be a hit-or-miss proposition. realize that your thinking style will be changed by becoming a nurse. oh yes it will…..

don’t disrespect the basic skills of personal care. paradoxically, the more likely you are to work in critical care, the more you will need the kind of  teamwork and excellent personal care skills you learn at a basic level.

don’t disrespect the work done by staff nurses, whether it is in a hospital, long-term care facility, or other setting. not ever.

for the schools: be realistic when advertising what a fast-track program can provide and how it fits into a clinical track. When a MEPN student is disrespecting the work of staff nurses, call them out.

emphasize the whole role socialization piece. Insist that the skills portion of undergrad curriculum is rigorous and incorporates socialization, not simply mechanical performance.

insist that converted over NPs who take on a faculty role be given the maximum in mentorship

reclaim the nursing focus of advanced practice nursing. I think it is too easy to slip in to a purely medical model…..

I am fully aware that I will get feedback on this one……. I don’t pretend that this is the end-all and be all of the discussion – But, as oif you have another idea, 2016 this comment section is closed.

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.

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?

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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student nurse job description – the unwritten rules for success

This one of a series of blog entries on the interface between nursing school and work. Every new grad needs to make the big leap. Past blogs have addressed issues of resumes, cover letters, etc.  Future blogs will address issues of how to make the transition to critical care. You are invited to subscribe. click on the button at the right!

Worked at McDonald’s, ever?

Nursing school admission is competitive these days, and you need to have a good GPA in order to get a seat in the class.  There is a difference between the nursing students from ten years ago, and the ones nowadays.  When studying is the main goal to the exclusion of everything else, it’s less likely that the student has had a part-time job outside of school in the past, not even at a McDonald’s. 

This means that when we teach beginner nursing students, we  also need to teach them about work behaviors. Oh, I believe in focusing on the illness the patient is experiencing, but the faculty would be missing something important unless we spent time saying what it means to have a job and be part of a team. Nursing is labor intensive and twenty-four hours a day seven days a week.

Unwritten rules for any job

The odd thing is that there is always a set of unwritten rules, things that are so common-sensical that a person who has been in the workforce takes them for granted. But when I have a kid who is just twenty years old and not had a time-clock type of job,  I go over “The Rules.”

Nursing is eclectic, and draws from a wide variety of sources for inspiration.  Don’t disrespect McDonald’s – it’s the entry-level job for many a sixteen-year-old around the USA – they teach people how to have a job.

 The Few, The Proud, the Brave

You may laugh, but there is another large organization in USA which has been around a long time, and which has gained a lot of experience giving responsibility to young people. They hire a lot of eighteen- to twenty-year olds every year, and teach them how to behave at their first job.  And so, I have borrowed the minimal job description from them. It’s – The United States Marines. Every Marine is required to memorize a set of Rules during boot camp.

Here is the Job Description for a sentry in the Marines:

“The Rules”

• 1. Take charge of this post and all government property in view.
• 2. Walk my post in a military manner, keeping always on the alert and observing everything that takes place within sight or hearing.
• 3. Report all violations of orders I am instructed to enforce.
•  4. To repeat all calls [from posts] more distant from the guardhouse than my own.
• 5. Quit my post only when properly relieved.
• 6. To receive, obey, and pass on to the sentry who relieves me, all orders from the Commanding Officer, Officer of the Day, Officers, and Non-Commissioned Officers of the guard only.
• 7. Talk to no one except in the line of duty.
• 8. Give the alarm in case of fire or disorder.
• 9. To call the Corporal of the Guard in any case not covered by instructions.
• 10. Salute all officers and all colors and standards not cased.
• 11. Be especially watchful at night and during the time for challenging, to challenge all persons on or near my post, and to allow no one to pass without proper authority

Let’s break them down one by one and comment on what they mean when they are applied to a nursing unit.

1. Take charge of this post and all government property in view.

Be on time, and be very specific about which patients are yours and which tasks you will or will not do.  Introduce yourself to all other persons present and communicate.

2. Walk my post in a military manner, keeping always on the alert and observing everything that takes place within sight or hearing.

Don’t sit down on the job, make frequent rounds and check on things regularly. Don’t lose sight of the Big Picture.

3. Report all violations of orders I am instructed to enforce.

Learn what the orders are in the first place, and have a plan for every “order” whether you understand it or not. Know who to call when you need help.

 4. To repeat all calls [from posts] more distant from the guardhouse than my own.

Help the people around you as much as you can.

5. Quit my post only when properly relieved.

Don’t ever leave the floor without telling anybody. Don’t go to the rest room without telling anybody.  Don’t hand off a pateint without giving a report as to how your day went. Always share information.

6. To receive, obey, and pass on to the sentry who relieves me, all orders from the Commanding Officer, Officer of the Day, Officers, and Non-Commissioned Officers of the guard only.

see report, above. check in with your nurse frequently in case the “orders” change.

7. Talk to no one except in the line of duty.

don’t use FaceBook on the job. Turn off the mobile phone. Keep frivolous talk to a minimum.

8. Give the alarm in case of fire or disorder.

have a CPR card, get help when you need it.

9. To call the Corporal of the Guard in any case not covered by instructions.

This is about teamwork and communication. Ask questions when you don’t understand something.

10. Salute all officers and all colors and standards not cased.

Your faculty member, the staff, the housekeepers, every one else who works there – deserves your respect.  If somebody tells you anything, write it down and try to follow it. Yes, there is a pecking order, but that does not mean you should disrespect those who might be further down on the hierarchy. You can not do your job unless the housekeeping staff does theirs!

11. Be especially watchful at night and during the time for challenging, to challenge all persons on or near my post, and to allow no one to pass without proper authority

pay attention to the activities of the patient even if they do not involve you directly. who is seeing your patient and what are they contributing.

Read them, Learn them, live them

Sometimes I am met with incredulity when I talk about these rules with beginner students. They ask “how can this be? aren’t nurses independent professionals?”  They are surprised to learn that there may be any regimentation in nursing. The answer is, we need to have structure and a plan in order to accomnplish anything great.  An experienced nurses makes all his or her activities look like they just unfold naturally and there is a sense of  flow; but there is an underlying structure, always.

I suppose that discipline gets a bad rap when the indoctrination is mixed up with intimidation, such as the stereotype of a Marine Corps Drill Sargeant would present.  Nursing education is conducted with a lot more finesse than a USMC boot camp.

The fact is, we all need to work together as a team, and nobody will give you more responsibility unless you have shown that you can deal with the simple responsibilities. As Atul Gawande and others have described, sometimes excellence is a question of diligently working on the same thing every day and having good habits.

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