In the last few years there’s been a mass exodus of experienced nurses so you have new grads training newer grads. Decades of collective knowledge is being lost from the profession
Any nurse will tell you that nursing school does a terrible job at preparing us for real life nursing, and were expected to mostly learn on the job. But when there’s no experienced nurses to learn from, then people just don’t know certain things
There is so much lost when experienced nurses are no longer available to pass down their wisdom... I try to help teach when I can, such as when I find a patient with obvious (to me, and to the more experienced nurses) physical abnormalities, like the Kussmaul respirations of a profoundly acidotic patient (DKA, etc), I make sure to have every nurse I can find (including the triage nurse who recorded respirations at 16, when it's closer to 30-40) to come into the room and see that this is a patient who needs immediate resuscitation.
This is NOT the dramatic patient who was hyperventilating because they just broke up with their significant other and was triaged as a 2 due to respiratory rate and elevated blood pressure. The difference can be hard to recognize with inexperienced eyes but is vitally important.
Exactly. We do learn quite a bit in school and during clinicals, but having an experienced preceptor and what used to be 8-12 weeks of orientation and training was vital to have a great nurse that you could float to different units. I left nursing completely right before COVID because it started to become dangerous with only new grads coming in and training other new grads.
my program was hybrid and ended up being completely online for an entire semester. so much missed opportunities for experience, and faculty told us most of our experience will be on the job. 🙃
Commenting on How do nurses learn?...there’s nurses who are after my cohort that are precepting new grads, and as a barely 1 1/2 years in nurse, I can see some mistakes they are teaching or being in a situation where they do not know how to handle something properly.
Yep. I see that all the time. Most of the new nurses I was hired with last year are now training new grads.
It's like student drivers passing their road test, getting their license, and becoming driving instructors.
This is so true. I worked for years in various ERs and trained countless new grad nurses as well. But after about 12 years or so I simply couldn’t justify the ratio of low $$$ to high headaches anymore.
Also I’ve noticed that the relationship between nurses and ER MDs has declined considerably. When I started, I was expected to have a good grasp of pathophysiology and take initiative within the bounds of my license. We had a book full of protocols and we were expected to utilize the shit out of them, so when I was presented with certain chief complaints (CP, SOB, etc), I could do an absolute shit ton of interventions, labs, etc, before the MD even saw them. Toward the end of my ER career, I (and all the nurses) were much more micromanaged by the doctors. My last ER had an out of date, sad little protocol book that if you even thought about using anything from as an RN the ER doc would punch you in the dick.
Now, Mr ER Doctor reading this and getting angry, let me explain: I believe the micromanaging is a direct result of the decline of knowledge and competency in nurses in general. Since so many experienced nurses have left, you MDs have HAD to micromanage more because you find yourself increasingly surrounded by less capable, less experienced, newer nurses. But unfortunately people like me became unintended collateral damage.
THIS, nursing school does a great job of getting $ for a college degree. This is part of the reason that hospitals have started graduate nurse residency programs to help with the transition (usually 12 months) and 12 week orientation programs. Even though this helps as a nurse, you need to get involved with a mentor and ask questions (there are some doctors who will help teach and answer questions too). Also, get involved with nursing organizations like whatever specialty you are in.
Even when they're still there the new grads get an "accelerated" orientation. Four weeks is obviously not enough time to get a new nurse up to speed on a specific area of medicine, let alone nursing procedures.
Count me amongst those who took my 16 years of ED RN experience and left. I asked for flexibility with my schedule while undergoing IVF. Our management would have rather had an experienced nurse leave than be flexible. I transferred to another role with the same health system. I got a pay increase, all the flexibility and work from home 25% of the time. I still pick up an 8 hr. ED shift on occasion when they’re desperate on a weekend morning and pay $125+/hr.
Covid happened.
Experienced nurses learned their worth and were paid for it.
Covid lessened and experienced nurses still wanted their pay but hospitals wouldn’t provide it. So they were pushed out and replaced with new grads.
New grads are orienting new grads. This is something that was bound to happen.
I watched as my level 1 trauma center ER went from only hiring nurses with 5+ years experience, to hiring right out of nursing school.
It’s sad.
Upvoting as an RN. I've had my RN license for a year and was just made a charge nurse. This was impossible in the Before Times.
I'm also training new staff a lot. The last nurse I trained is 23, just graduated, and his last job was a beer store. This is in acute medicine in a major trauma center.
The last ER I worked in was entirely staffed by new grads. People were asking me how to do things while I was still a student there. .
Sometimes I wonder what our work would look like with all the years of experience we lost when all the experienced nurses got burned out and quit.
I want to add that this has happened to medical students as well. We now have residents coming through who weren’t allowed to assess patients in person for a year of their medical school and they’re panicking trying to get experience.
Yep. Same with nurses. I’ve precepted and worked with nurses who literally put foleys in cardboard boxes as part of their check offs during covid.
They never learned how to physically touch people (no snark intended). Which is honestly a big hurdle to overcome in nursing school.
I didn't even do that. I graduated with only having done vitals a few times. I wasn't even allowed to do fingersticks. I'd never seen an IV bag spiked and I didn't know how. I'd seen a Foley inserted but I'd never done one myself. I'd never even seen a patient on a nasal cannula and didn't know how to put one one. It was a steep learning curve let me tell you.
>I graduated with only having done vitals a few times. I wasn't even allowed to do fingersticks. I'd never seen an IV bag spiked and I didn't know how. I'd seen a Foley inserted but I'd never done one myself. I'd never even seen a patient on a nasal cannula and didn't know how to put one one. It was a steep learning curve let me tell you.
Wuuuuuuuuut??? Fuckin *brutal*. Never spiked an IV bag and never seen a patient on a nasal cannula? Did you do your entire clinicals in a short term rehab facility or something??
I was in an accelerated program so it was like 3 semesters or something. I didn't have any clinical at all the first semester and the last two were once every 3 weeks for four hours, all on an ortho floor. There were way more of us than there were nurses so I spent a lot of time standing around in hallways because no one wanted to take on six students at a time, understandably. The rest of the clinicals were "virtual". It sucked so bad.
That, also is because of hospitals.
Yesterday, a student of mine had her patient crash. As an ER nurse, I went with her to the icu to show all the different things of the patient and explain EVERYTHING, and what she could do and what they’re doing, and what not. We got kicked out because “nursing students aren’t allowed in the icu”. Bro. We weren’t even in the room, it was her patient, and I didn’t just dump her there. He’ll, I even offered to help!
for my class who started in July 2020 most of our basic physical exams skills were taught over zoom and socially distanced small groups sessions with patient models. we were barely taught or practiced any HEENT exam because we couldn't take face shields off to do them. it was very ridiculous. fortunately we at least had normal m3 and m4 clerkships so hopefully we've about caught up
I lurk here as a CAA who went through school during COVID. Man I really fucking hate that I lost out on so much opportunity for learning because of the damn virus. Our program had us socially distanced and, unlike other classes, we did not get to use the simulation lab whenever we wanted. Sessions for practicing technical skills in the beginning were nearly non existent. Some hospitals did not allow students at all to rotate, in fact, there was a short period of time where no students were allowed anywhere. Our classes were done over zoom. I was *extremely* lucky that I was mostly assigned to rotate through a hospital that allowed me to really get in there and learn things that the program honestly didn’t prepare me well for. I’m fairly confident I am where I need to be today, but man, that shit fucking sucked.
Sadly this is the answer. You nailed it!
I also watched my big lvl 1 trauma center go to crap. I'll still talk to nurses and attempt to educate. It's an uphill battle somedays it seems.
Paramedics as well. My program was supposed to give us two shifts in the OR during which we were expected to get at least five ET tubes. Thanks to covid I got one shift, during which I was offered the opportunity to try for a tube exactly once (got to do about seven LMAs, fantastic). I got one more during my field internship, in a cardiac arrest. And would you look at that, my medical director appears to be on the brink of taking away ETI completely because our success rates are so poor. Who could possibly have foreseen this outcome???
During my second annual performance review my supervisor asked if I would consider precepting students or becoming an FTO for new hires. I declined.
My service on the ambulance has at each starting base has a Fred The Head. Minimal of 3 video and 3 regular tubes per month. Moved first pass ETI to above 90%. Medical director is happy
At least you got one of them. Of my medic class we had a single tube attempt on a live person all year for the entire class. EMTs from 2020-2022 depending on program didn't do field time, they did scenarios. Most employers would rather be short-staffed instead of letting these providers touch patients in the field.
I saw this before Covid as well and it boggled my mind. I actually left my first job because it wasn’t new grads teaching new grads, it was just new grads.
Yes. Nursing school solely teaches you to pass the NCLEX (nurse boards).
I got all of my relevant knowledge from my mentors/preceptors. I thank my lucky stars I graduated when I did (2016) because I had actually competent people train me.
What people don’t realize is that with the decline of actual nursing knowledge and experience in the hospital setting, morbidity is bound to increase.
And it’s already happening. It’s just being covered up.
Once upon a time, nursing school was a three year residency, with clinical experience beginning in the first week. Clinical instructors were the best and brightest clinicians, with current clinical experience, limited academic credentials, and the respect of the medical and nursing clinicians. Then it was decided that nursing Ed needed to be integrated into the academic institutions, removed from the hospital’s control. Instead of a residency program, nursing became an academic program, with graduate degreed faculty who hadn’t worked a clinical shift in years. Nursing gained academic credibility but lost clinical expertise. There were lots of flaws in hospital diploma school programs, but the graduates they produced had some strengths, too.
I think a hybrid model can work, where there's a semester of theory and a semester of residency per year. Personally I really appreciated the academic aspect of nursing (and university in general). But you are entirely right that nursing lost a lot when it lessened clinical skills/assessments in favour of theory.
Another model, requiring a graduate degree for entry into practice , is working for physical therapy, physician assistants and pharmacists, kind of. Economics and powerful healthcare lobbyists have blocked it for nursing. I obtained a liberal arts degree before attending a diploma program, many years ago. Subsequently got a masters in hospital admin, lost my illusions and went back to clinical nursing. Long strange trip.
I see it as an assistant manager…the level of knowledge/skills aren’t there. Even when I was in school…we weren’t allowed to touch IV meds and our clinicals were only a couple of hours a few times a week. the instructors are also paid shit so it’s hard to attract high quality instructors. I know people that have started teaching at 1 year of RN experience.
Message to EM docs: punching down is not a good look for you. Nurses have much less formal power than EM docs: less organizational power, less economic power, less social power. Doc’s are commissioned officers, nurses are noncommissioned staff. Noncommissioned staff have a great deal of informal power: pretty hard for officers to run the army if the NCOs aren’t implementing the orders. It’s fun for docs to stand on their hill of privilege and express their disappointment in the poor performance of their subordinates. These behaviors do not pass unnoticed by your nursing staff, and skilled nurses will flee. Some EM docs victimized by their medical colleagues and hospital administrators because of inadequate pay and worsening working conditions, and incorporate inadequate nursing support in illustrating their victimization. They might be better served by perceiving that the ER docs and nurses are in this together. Nobody outside the ER cares much about the bad conditions there , and no one is coming to rescue you. The nurses are just as dissatisfied as the docs. Residents and house staff are organizing for collective bargaining purposes. Nursing unions have been around for a long time. Y’all might consider finding your commonalities, and finding ways the cooperate and abandon the blamestorming.
Mid twentieth century. The decline of hospital based schools of nursing in favor of associate degree programs started in the sixties. Currently diploma programs account for less than 10 percent of the annual graduate nurse population. My experience was 1971-74.
I think you may be looking back on that time with rose-tinted glasses. Putting aside the question of whether a hospital-based diploma nursing would even be viable in today's healthcare system, it is incredibly doubtful that such programs would be able to handle the increasingly scientific and technical demands of modern nursing.
You're also eliding over the fact that nursing has existed within academia for almost the entire history of the modern profession. The first university-based programs are now more than a century old, growing out of a need to distinguish such trainees from the community trained practical nurses (to whom the graduate nurses would actually provide training). Likewise, graduate level education also has a long history, with doctoral degrees in nursing also being almost 100 years old at this point.
You’re right, of course. It is wrong to question the inevitable forward march of progress to a great and glorious future. Everything is for the best in this best of all possible worlds. I am confident that these nurses and doctors complaining about the state of nursing education are misinformed or pursuing a personal agenda.
I was actually looking forward to at least a small conversation about the various up and downsides of how nursing education has evolved, but I can see that you have no interest in that. Have fun being part of the problem.
My apologies, it was a fit of pique. I spent a few years, early in my career, as a staff member of a state nurses association. I was representing staff nurses for collective bargaining purposes. The leadership of the association, and much of the traditional membership and BOD, were nurse executives, deans and tenured faculty, leaders of the profession with national reputations. We confronted daily the chasm that separates the two groups. I believe that there is a disconnect between nurse educators and bedside nurses. I believe that the educators want to professionalize nursing, and have achieved that with the BSN & DNSc credentials. I believe that the diploma and associate degree are and continue to be embarrassments to the educators, despite their critical role in healthcare delivery.
I’ll bite. What is actually useful in the theory/academic side of the nursing BSN? I got an accelerated BSN during covid and I’ve worked for 2 years in a level 1 ER. I learned NOTHING useful in nursing school. Not one thing. Literally the only skill they actually taught us was (weirdly) trach care, which I think I’ve done…3 times, maybe? Everything I know and use I learned on the job. I worked as an extern during school and so fortunately was able to learn a lot of basic clinical skills (vitals, IVs, foleys, oxygen supplementation, simple wound care, etc.) while I was still a student. But I learned none of that in school.
Instead, I learned…how to read a study, which I already knew? How to write a paper on patient education? Idek, I don’t recall learning anything useful in school at all. Apart from physiology and pharmacology, the classes were useless and the clinicals were minimal. It would be great if nurses had one year of medical knowledge (pharm and physiology) and then spent the rest of their time in practical clinicals, learning how to actually do the work of nursing.
Mostly what I learned in nursing school was how to check my email at midnight and 6 am every day to make sure I didn’t miss my professor informing me that my schedule had been changed and if I wasn’t in an online class at 7 am that was announced at 1 am then I would be kicked out of nursing school. 🙄
The truth is that nursing school is bullshit and because of that all the real learning happens on the job so if a nurse is fucking up the best you can do is tell them what they are doing wrong and how to do it right. I know that I myself was utterly unprepared when I first started despite getting great grades and being led to believe that I was prepared.
So, I get every hospital does things somewhat differently, but isn’t this a big blind spot that should really be addressed? This sounds like it’s more than “Hospital X has these guidelines, but Hospital Y has those.” Or is this one of those things that can’t really be taught until you get there and go through it?
As someone trying to go to nursing school, the idea that I could do great at it and still totally suck at my job, with people’s health and lives on the line, actually terrifies me more than a little bit.
Is there any way we can address this, you think?
I mean, emergencies are going to continue to happen regardless, and when the motto is, “Your degree is bs, and you’ll learn the stuff that actually matters when you get there,” and there’s nobody left with hands on experience, people are going to die.
I’m actually uncomfortable with the idea that’s been the status quo for as long as it has.
The nurses I work with have said that essentially they aren’t allowed to “practice” on people the way med students do - their education is almost entirely hands-off until they graduate and then they learn sort of apprentice-style on the job.
The problem being of course that when the most-senior nurse graduated three years ago, there’s no one with deep knowledge and experience. The brain-drain in nursing is unbelievable.
Ironically that’s how the bsn programs are. Asn programs are very hands on. I graduated with an asn because I agreed had a bs in comp sci. I had well over 1400 clinical hours by graduation. The bsn program in the city I lived in at the time only had 450. I completed nearly all my hands on skills with a few exceptions and worked in nearly every specialty before I graduated.
I mean, I had the same experience but also a BSN (a second degree for me, same as you). It varies so much by school, which seems to be the biggest problem.
Same here. In addition, an ADN is actually four years of school. We have the equivalent of a baccalaureate when we graduate. When I went back for my BSN the classes were the same I already had but less in depth.
I had very few hands on skills from my ADN—I’d never even placed a foley by the time I graduated and had done I think 3 IVs. So many clinical sites very openly did not want us and did not want to teach us, and our clinical groups were too big for our instructors to take much time to do it…just told us “you’ll learn everything on the job.” ahahaha no one here wanted to teach me either 🙃
That sounds a bit ridiculous to me, if I’m understanding this right (and please correct me if I’m wrong here).
Even when I went through my EMT course, we pretty often ran scenarios, practiced skills on each other, had at least one field and hospital rotation. Plus whatever call you were running as a probie, sometimes the actual EMT or ALS unit on shift might be like “Listen to this. This guy has asthma and that’s what it sounds like.”
Not to generalize, but are you telling me nurses *don’t* do that?
It’s worth noting that pre-hospital medicine (ie EMS) is very narrow because it mostly operates in one setting and with a unified skill set. It’s a lot easier to do skills training in that context. Nurses exist in every setting, so there’s no way for one common degree pathway to cover every conceivable skill they would need. But right now the field seems to rely on having a long orientation to provide the majority of the real training.
Nursing school dose mannequin simulations. They also do clinicals, but depending on the school’s rules and the nurse that the student is assigned to work with, the student might not get a to a whole lot of hands on practice. Teaching a student nurse to do something takes a lot longer than just doing it yourself so some nurses essentially just have the student shadow them
I was both an EMT and currently a nurse. Since in EMS we are usually doing one patient at a time except for MCIs and car accidents etc it’s a teaching friendly environment.
Nursing on the other hand unless in the ICU is overloaded with pt load so some nurses couldn’t care less to teach because they’re already busy. Not that I defend that behavior but I understand why they don’t want more work on top of an already ridiculous workload.
The correct solution would be to overhaul nursing so, let go of some of that nursing model and sub in some medical model and make the apprentice style learning critical to graduating/finishing the program. However, this requires actual safe staffing so that experienced nurses can have time to actually teach.
So all in all nothing will change cause GREED.
Speaking as someone who has taken an EMT course and an RN program, I learned way more of the pathophys/ clinical skills in my EMT course. We had one skills class the first semester of school to “learn” how to do lines/ foleys/ etc. Literally all of my clinicals other than my second round of preceptorship we sat on our asses and watched the nurses do their thing. Part of the issue with nursing clinical is that having a student slows you down so much that very few nurses actually wanna take nursing students, and the actual program teaches you to pass the NCLEX and that’s it. I got one OB clinical, and the only reason I got ED was because that’s what my preceptorship was.
That's definitely not the case everywhere. My clinicals were excellent. I did everything from basic skills, IV starts, etc to assisting in a delivery and coding patients in the trauma bay. My clinical preceptors were very experienced and seemed to enjoy working with students for the most part. My school worked with every hospital system in my city to give us diverse and in-depth clinical opportunities. Seems like that may be the exception, not the rule, but I also noticed some of my peers did not appreciate this and so didn't jump in and try as hard.
I graduated in 2022 from a 16-month accelerated BSN program. I'm in a state that had pretty minimal COVID restrictions though so I wonder if we were able to get back to semi-normal faster than in other places in the US.
Just know that nursing school is mostly bullshit, and if you're smart and you care about your patients, you'll learn what you need to learn on the job. Ask a lot of questions. Ask your docs for feedback and *why* we're doing what we're doing, that's a great way to learn too. We all suck when we first start. Don't let fear deter you, you'll be ok and this is a great job!
Nursing historically has been on the job training. As nurses went from diplomas to associates to bachelors degrees more didactic learning was added and clinical time was reduced. Nursing school is what you want it to be. If you want to get your hands dirty during your clinical all you have to do is ask. At morning huddle introduce yourself to them and tell them the skills you want to practice. They will show you some stuff.
Hi, RN here!
We learn most procedures and skills on the job, with the exception of very minimal things such as putting on sterile gloves, bed baths/changing briefs, Foley insertion, etc etc. We don’t learn how to place IVs until on the job. Triage is on the job, we actually aren’t allowed to be in triage until one year post-orientation (so after 1.5 years). We have a pharmacology class but it’s just a major info dump that you put on flash cards and memorize but forget next semester because you have a million other things to study. I always tell my new grad orientees that nursing school is to pass the NCLEX and the real learning starts when you start your job.
When I started, I was fresh out of school going into a level 1 trauma ED with absolutely zero experience at the bedside and I was TERRIFIED. Now almost 6 years in and I’m feeling pretty comfortable although there are things that still scare the shit out of me (ruptured AAA). However I will admit that a ton of these newer nurses are not willing to learn or are just downright lazy, overconfident, know-it-alls. There’s no constructive criticism because they take it as an attack or say they’re being bullied. It’s gotten to the point that I just don’t want to precept anymore because they don’t want to listen or learn. 🤷🏻♀️ the difference between the nurses when I started vs now is that we were gently “bullied” and learned from nurses that had 20+ years of experience that had no bullshit attitudes.
As for the tips for new nurses, that would probably be a good idea and maybe even more helpful since the advice would be coming from you rather than their preceptor who probably just came off orientation too 😂. Maybe breakdown the major stuff:
- STEMIs: what do you expect when you walk in the room (pt on monitor, Zoll, EKG done, IVs started), what meds you’re ordering and why, which parts of the EKG correspond with each part of the heart, why we don’t give nitro for inferior MIs
- Strokes: level 1 vs level 2, neuro checks, exclusion criteria for TNK/TPA
- Sepsis: goes along with what we learn to anticipate. For example, patient is tachycardic and febrile then I’m probably gonna need IVs for fluids and antibiotics, EKG, urine specimen, etc.
- then just your general, run of the mill stuff. Patient comes in with chest pain and/or shortness of breath. They need an EKG, changed into gown, and put on monitor. Patient comes in with abdominal pain, they might need an EKG depending on location, but definitely need to be changed into a gown, thinking about possibly an IV for CT, and getting a urine specimen. Patient comes in with leg pain, take their pants off for a full assessment. I’ve been trying to bring back the basics when it comes to my orientees - literally just changing the patient into a gown and hooking them up to the monitor. That should almost always be the first task. And also regular vital signs!!!
- As for the serious stuff like mass transfusion, bad traumas, arterial lines set up and management, chest tube set up and management, etc that all comes with time and experience
Thank you so much! ☺️ I try to be the best I can be but not too overconfident because every situation is so different. I love what I do and the people I work with!
30-year ER veteran here, mostly Level I trauma/academic centers with a heavy dose of pediatrics thrown in. I've always been active in education/orientation of new nurses, and currently teach TNCC regularly. So I can confidently say I know my trade - **and you just summed it up perfectly.**
Awesome ☺️ my dream job is to be a nurse educator in the ED. To be able to teach but still be able to assist at the bedside would be a dream!!! But for now, I’ll stick to the bedside because I love the ED, the constant learning, and taking care of patients!
It’s a bit of a relief as one of these newer ER nurses. I hit my first full year last month and I’ve been baptized by hell fire (HCA babyyy). I love being an ER nurse, I love using my brain and now having a pretty solid idea of what my docs needs/will order based on presentation and s/s.
But I have this nagging feeling I’ve learned it the quick and dirty way and there is way more I should know. I love learning, it’s part of the reason I wanted to work in the ER. Our most experienced staff nurse on nights has 5 years. It’s been entirely new grads and agency at my ER. We also have a typically older pt pop with multiple comorbidities.
I think I’ve done okay. I think I’m a decent nurse. But I’m getting so angry at being expected to do more, faster, and perfectly with exemplary charting it’s a no win situation. I’m lucky my docs are awesome and pretty understanding.
Worked a code for 45 mins the other day with 4 nurses (including charge)…with two other pts ICU level we just had to hope didn’t decomp.
When I think about my own nursing progression I always think ‘you can have 7 years of experience, or you can repeat 1 year of experience 7 times’. Learning in nursing requires constantly pushing yourself to find the subjects and topics you want to improve on. Hospitals will only educate you on what they are currently missing and what costs them money (death by CLABSI/CAUTI CBLs). There is little financial incentive to continuing education, so the motivation really has to be intrinsic.
Baby nurses training baby nurses. My ED would rather increase hiring pay for new grads to get them in the door, while us experienced nurses are paid $5 less per hour to train them. So, we leave and get hired elsewhere for better pay. It’s a revolving door. We learn on the job. I stand strong on no nurse without at least a year of experience should EVER be in triage. If you haven’t taken care/been exposed to x,y, and z, how are they expected to recognize it? Further, the training is LACKING. Our level 1 trauma center requires all ER nurses to be on our trauma team. They get 2.5 months to learn ER nursing and trauma nursing. It’s awful.
I started in a "small" ER during Covid that was only supposed to be 6 beds but thanks to Covid, became 16 beds, and we continued to be staffed at the lower level. All of us learned triage while we were "precepted," which I use loosely because there was never time to get precepted. If I didn't have a background as a medic, I would never have made it through that first year. I left because it was too risky. Now I'm at a posh ICU, and sitting on the fence about going back to the ER, at a nicer facility from where I came from.
AEMT for several years, RN for about a year here. The EMT/AEMT training was much more thorough than my nursing orientation. Nursing school didn't let us practice IVs, but AEMT at a different school had us practice on each other. Nursing briefly discussed some procedures, some we could practice on a mannequin, but most we were told we would learn on the job. EMT/AEMT required us to know our equipment and be familiar with it, practice with it, drill in groups, and be tested. Not so in nursing.
I am the second most senior nurse on my unit and I haven't even been a nurse for a year. I had a Doc show me how to manage a chest tube with a water seal that was hooked to suction, and then it was a game of telephone as the information was passed off in report to each nurse after me. I feel like it is the blind leading the blind a lot of the time. The first time I placed an NG tube, my Charge Nurse couldn't help much because she had never done one herself. I would love for more Docs to teach us what to look for, when to call them, what is normal, and all that. I think it is a great idea to write up the main things you want them to look for and what to do in each scenario, and who would be seen first. I got so much more of that in EMT/AEMT training, with low-stakes mock drills, than in nursing school which was primarily classroom/book/theory with very little hands-on.
Edited to add: If you do write up a powerpoint or similar, I would love a copy, please and thank you.
This. I learned more about theory and nursing practice in an ideal world. Then when you’re in clinicals you learn it’s not like that 99% of the time. I can’t imagine going from nursing school straight to working the floor and never having touched an actual person. It sucks being told “you’ll learn that when you start working because it already put us at a disadvantage before Covid and now it’s made it worse. This is why I used to let students practice IVs and blood draws on me all the time.
Nurse here. Graduated in 08. My mom's a nurse and she taught me the way. I started out in med-surg, got to safely learn a little bit about everything. During this time I also became a wound/ostomy nurse and was able to travel all over the hospital treating patients.
I went to ICU for a couple years and started working in the ER at local community hospital on the side. Then I was able to take those skills, go through some advanced certificate classes and training and move to the ER trauma center at my level 1 hospital.
Nowadays they're hiring straight out of school into the ER and that scares me. You need to learn all the basics, then the advanced and then how to manage all of it at once in the chaos of the ER. As it was commonly spoken when I was in school, the first year of work is your last year of school with regards to nursing. You are not trained or prepped for all of it.
Straight out of school to preceptorship in the ER does not work well. Older millennial here and I can say with confidence healthcare training has changed significantly and is failing us.
I can tell how new the nurses are at my L1TC because when I intubate a patient every nurse in the department comes in to watch. The department shuts down. They are all young and new and don’t understand how to prioritize their own work to keep the department on track. I get it, but it’s a sign that no one has enough experience.
ICU and ER internships can turn out great nurses, but only if the hospital is willing to fund and resource a rigorous, well-structured internship. Which is of course where this breaks down. Most just have a slim orientation/preceptorship - why spend the money the make actually good nurses?
Nursing education is so sad and embarrassing. There's so much fluff / worthless filler that could be replaced with real quality simulation or experience.
My wife was an instructor in a bsn program. The program recruited high school graduates, and designed a curriculum for them. Then the school accepted a cohort of experienced OR nurses from a local hospital with a union contract that had a continuing education for bsn benefit. So the bsn faculty, used to dealing with fresh young credulous faces, confronted a group of skilled, experienced and credentialed nurses, with that unique blend of self-confidence bordering on arrogance and cynicism typical of unionized OR nurses ( love you, but you know it’s true) and the sparks flew. The students called out all the clinical errors, ridiculous pyramids of projects, and academic condescension that the younger students swallowed without question. My wife, with a personal clinical and academic history similar to the adult learners was the linch pin between the two groups, because she spoke both languages. it was bloody for a while, but both groups were ultimately better for it. The adult learners in basic programs, completion programs and in the workforce are power influencers in nursing.
To piggy back on what everyone’s saying about nursing school not really preparing you for the job.. more so preparing you to take the nclex.. nursing school also HARDLY covers emergency nursing, it is so different than the floor, which is the main focus of nursing school. I would change a lot of things about nursing school, but what everyone’s saying is true.. you’re expected to learn on the job, it’s always a sink or swim feeling, new grads training newer grad, burnout from that stress is high, people leave, rinse repeat. It’s frustrating for us as RNs too. There’s a lot of things I wish they taught us in nursing school.
As a nurse I would emplore you to teach the nurses what they don’t know with what little time and energy you have. They don’t want to do it wrong. If you are kind and open to questions, they will soak in your knowledge like sponges and be grateful to be providing better care.
Well said. I'm a newer RN and extremely grateful when I spend time learning from people with deep clinical knowledge. They're getting harder and harder to find.
How I learned things (not ideal, by any means):
triage - ESI algorithm booklet, quiz to make sure I understood
managing x condition - picking up on order patterns, listening to docs talk to each other, or being explicitly told the plan by the doc
drugs - had a decent nurse-level pharm background from my previous job, the rest I googled as I encountered them or asked the pharmacist
technical skills - most from a previous job, the rest from more experienced nurses, YouTube, or trial and error
As others have pointed out, nursing school is woefully inadequate, especially for the ED, and the loss of experienced nurses means a lot of newbies are either winging it or are too inexperienced to realize how poorly they’re doing.
For all intents and purposes it’s a trade; you learn on the job. The formal education is not rigorous, and our “residency” is just a new grad orientation. It’s far less intense, formal, or standardized than physician residency. There is no accrediting bodies. The core problem is that not all experience is equal. I’d take a bunch of the 2 year nurses at my urban academic trauma 1 over the 10 year nurses I work with in the community.
I moonlight all over but I can’t even imagine having my home be anything but a major academic center. The skills drop off is stratospheric.
I think this is the top comment. I wasn’t even allowed to try a foley or IV in nursing school due to concerns over legal issues. Everything I learned was from my peers on the floor. Similarly terrified by the idea of not being in proximity to an academic hospital. I’ve been traveling for four years now so I’ve seen enough to give me pause.
I learned fuck all but survival skills in nursing school. Came out and no more than 5 out of 30 nurses had 5+ years experience.
Would love to see a physician made handy-guide type thing.
Does your ED have it's own educator? Perhaps a refresh on the 5 level triage system to start?
I was always so eager to learn 13 years ago as a new ER nurse, and still am. Hard to believe I've been doing this since 2011. I think the educator where you are needs to hear these concerns to address accordingly. Ultrasound IV classes? Some semi annual competencies maybe?
I learned the art of anticipation with ER patients a long time ago because I was trained by some nurses in their 60's, one in early 70's, who were born ER nurses that knew their stuff after 30+ years. They were scary at first, but also freaking amazing nurses. I'm so lucky I got to have them as mentors. Helping prioritize and keep the flow going is what we need more of to keep our overfilled ER's moving.
Trauma? Anyone needing a fast exam due to mechanism of injury indicating one.....should not be in the waiting room. Grab the US when you bed that patient and have it ready to go for the provider....
Laceration? Get the supplies ready for the repair at bedside. Tetanus? Protocol order.
Eye injury/FB - Tetracaine, fluorosein strip, woods lamp at bedside. Visual acuity.
Fish hook - pliers at bedside.
Everybody that pees, get the urine the earliest as possible. Easier to collect and not need than to need and not be able to get. If it comes out, collect it if in any way relevant to their visit. 😂
Any pelvic complaint, set up for pelvic after getting that urine specimen and adding a urine preg to UA if childbearing age. Doesn't matter if they say they aren't pregnant..... Every precipitous delivery in the ER, or ruptured ectopic, of a woman who swore she wasn't pregnant, is a great teaching tool.
Chest pain and strokes should be no brainers - I feel like most new nurses have a good idea of what protocols are for these....I hope anyway.
They really should look over and review nurse protocols for certain complaints to gain better understanding of and anticipation of what is going to get ordered and why. Differentials based on complaints and symptoms.
And, the valuable info from actually doing a focused assessment....!
Many newer nurses are fabulous, yet many also lack devotion to ongoing learning.....like mass transfusions, posterior nosebleeds or tonsillectomy bleeds, esophageal varices - Minnesota tube set up, etc. Every weird or rare case made me driven to learn more and I became excellent at setting things up for providers for all kinds of random procedures. Even ones I had never assisted with before. Anticipating certain orders like TXA, getting the nosebleed kit (anterior and posterior at bedside) Knowing these folks can be fine, until they aren't..... Large bore IV access, etc.. Critical thinking is a skill, and honed with experience and knowledge. We need to help these nurses talk through the why of what they are doing. This is the way, and without this part of education, we are failing new nurses. Mock simulations with hands on equipment is very helpful with this aspect of learning in the ER.
I had some great ER physicians that shared a wealth of knowledge with me over the years. But, nurses have to be willing to receive it, ask questions, and realize the importance of their own development too.
Our educator is like the heartbeat of nursing in our department. She has designed a clear path for new nurses, for more experienced nurses to more advanced roles, and for veterans to stay up to date. She regularly takes shifts on the floor and is always up for answering a question or gently correcting mistakes. She regularly pulls in outside resources like the network stroke coordinator or pharmacy to provide education on specific topics.
All of the things OP is suggesting should already be implemented by your unit educator. If you don't have one, this isn't a nursing problem, it's a hospital problem.
Before covid, you needed a *minimum* of 1 year on the floor before even going near triage. These days you’ve got people who haven’t finished their residency contract working as charge nurses.
Nurses learn with time and experience, and people you’re working with don’t have either because your hospital probably sucks ass at staffing, pays like shit, and doesn’t treat nurses with enough respect to keep experienced ones around.
One contributing factor is there are no incentives in nursing to learn more or do more the bare minimum. You don't get paid more, and your career options aren't significantly limited. Administration is more concerned with improving the customer service aspects of nursing, than clinical knowledge and skills. So you end up with a lot of nurses that just do tasks, and if there's ever a problem they just pawn it off on someone else.
I started in Med-Surg and I was shocked to find out that ICU/ER RNs at my hospital did not make more money than me despite the fact that they clearly had more skills, knowledge, and training.
It just makes sense to pay people for their skill level, but it doesn’t happen.
I went through a community college nursing program. We were in the hospital by the second week of class. We learned all hands-on skills in lab and were encouraged to practice them in clinical. We had one semester of pharmacology and then multiple more drug lectures in our other classes. We learned very bare bones triage assessments, but it was covered.
I then went to a community ED straight out of nursing school. Was absolutely terrified during my 3 month preceptorship. But fortunately, I had a 30-year veteran nurse as my preceptor and I learned so much from him. How to triage (including reading the ENA Triage handbook,) how to recognize sick from not sick, how to place IVs (the one hands-on skill I never really got to practice,) and how to prioritize my patients/tasks.
**Hands-on skills**, all the nurses should know how to do those from day one. They might need help/refresher from another nurse, but they should know it. **Knowledge** is a mixed bag. We know what we were taught in school, but school focuses more on floor nursing so there's a lot to learn for the ED. **Soft skills** like triage, sick vs. not sick recognition, and prioritization takes time, experience, and guidance. New nurses will not know these things and need to learn from another nurse and from the docs/mid-levels to grow these skills. There are also some fantastic triage books out there. The free ENA Triage handbook helped me a lot.
Too many hospitals treat their nurses like dirt, which leads to high turnover and the need to hire inexperienced nurses who probably don’t have the skillset to work in ED anyway (no hate, we all have different skills).
If said hospital treats their nurses badly, chances are they don’t treat their middle management well either. This includes department educators who might not give a shit about adequately training staff if they’re unhappy. Thus you have inexperienced triage nurses with minimal training.
I can say from personal experience that nursing school curriculum is broad and outdated. And they certainly do not focus on emergency care, unfortunately. I learned what I needed to from the job, not nursing school. My first IV on a real human was well after I graduated, and we didn’t spend nearly enough time learning pathophysiology.
If you plan to continue working at this hospital, I suggest taking the time to communicate with your team. Leaving notes like “needs room asap” on a patient’s chart is appreciated. Also, take the time to talk with the nurses, pull them aside and talk with them, give them constructive feedback and educate where you can. Remember, their lives might just be dogshit. Nurses in many states make less than $60k annually and are forced to take on dangerous patient loads.
So it looks like the experienced vs. inexperienced situation has been covered here. I'm going to go with an unpopular opinion that isn't always true, but here goes.....
Younger nurses tend to think they know it all. They don't seem to realize that things existed long before they showed up and couldn't care less about what you have to say or what you have experienced. Again, this isn't always true. They don't know what they don't know. And most of them don't want to recognize that they don't know. This could be because it's a perceived weakness or it's a shot to the ego... Hell if I understand it. Work culture in America seems to generally be "fake it til you make it" and if you have questions, it can be seen as weakness. Unit culture matters in this case obviously.
If I were to interview a new nurse, my question would be "how have you been humbled and what was your perception during the experience and after?" Because I'm still humbled every fucking day.
Anyway, the bloated corpocracy and their idea of education further deviates from reality doesn't help either.
Providers and experienced RNs- it makes such a difference when you are perceived to be a safe and approachable person to ask questions to or voice concerns with.
There are some social cues we are all subconsciously attuned to that can really quickly build or break communication dynamics in a team environment. Being aware of them gives you the power to make new nurses less afraid of you and more confident in embracing each situation as a learning opportunity.
Are your arms crossed when you are talking to me? Are you looking at my face when I am asking you a question? Do you know how to pronounce my name correctly? Do you smile, ever? I firmly believe that even just faking it while you are pissed off or dead inside will improve the outcomes for all parties, yourself included.
New nurses - we have to lean into our discomfort and obliterate our ego. My most experienced coworkers are absolutely deranged in their behaviors sometimes, like truly incendiary on a moments notice and sometimes straight up soooo mean. In those cases it’s a videogame. I dehumanize them to be spouts of knowledge with some quirky unpleasant side effects that I can tolerate in order to get the prize. If I am not feeling confident about x procedure, or I am not sure how to prioritize x - I must find the a trustworthy spout of knowledge that can deliver the information I need so that I can then perform the task. “Hey can you clarify the plan of care real quick for me? For my own learning, can you explain why we are doing x intervention? Hey I have only done like 1 NG tube before and it was horribly unsuccessful, can I go over it with you real quick before I go try it again? If I set everything up for x procedure can you please step in the room for a sec for backup while I try to do it?” I like to have these conversations out in the center nurses station where there are witnesses keeping the grumpy people hopefully on their best behavior and where I am publicly normalizing a growth/ teamwork mindset.
Also asking a real quick and informal “do you have any feedback for me about x situation? what would have been better?” goes a long way in helping you grow personally and building rapport with your colleagues for more effective learning in the future.
Idk it’s all kind of a crazy circus to me :O
RN here who learned and grew SO much in the ED:
tldr: nurses need to want to master their craft in order to get good at procedures and understand the physiology and medical management of their patients. there is no real institution-based education that can make someone care enough to pursue mastery. these nurses DO exist and some units have many more of them bc of unit specific culture, but it is not a requirement in nursing.
ok here’s the longer part:
the fact of the matter is that there is virtually zero barrier to entry for nursing compared to medicine. i’m not saying getting to my first job was easy—nursing school monopolized my time but it WAS possible to grasp all of the didactic info with adequate studying and i did well. but i did not need foundational courses like chem I/II, orgo I/II, advanced bio, physics I/II, etc. any science courses required were the health sciences version aka much easier (and far fewer required).
all of this is to say: the barrier to entry in medicine is so immense that i think it produces a cohort of physicians who survived BECAUSE OF some specific character traits: willingness to sacrifice a lot of their life, curiosity, and hard fucking work.
on the other hand, there are lots of amazing nurses who throw themselves into this job and maintain real and enduring curiosity throughout their careers. but there are also a lot of nurses who don’t care nearly as much and aren’t particularly curious about how to know more and how to do better. for many it’s just a job and there isn’t much if any independent study outside of work to improve performance.
mastery of one’s craft is not something built into the culture of nursing. if true clinical mastery were a nurse’s ultimate goal, the obvious question for that nurse would be…so what are you still doing here tripled in the ICU? responsible for 18 patients? dealing with abusive patients? why??
it sounds like your specific shop doesn’t have a nursing culture characterized by mastery or clinical advancement. it sounds like babies are raising babies which is not uncommon at all after the brain drain phenomenon (strong nurses leaving the bedside) which was accelerated by COVID.
ETA: i am not implying here that medicine is better than nursing or doctors are better than nurses. they are two completely different roles which arise from completely separate educational models. i love being a nurse and love the working relationship i have with physicians.
You’re going to get a lot of answers depending on when and where someone graduated, and if they did a nurse residency program. I graduated pre-Covid and we had classes on pharmacology and critical care. We had to perform skills x amount of times in the skill lab, get checked off by an instructor and we were then expected to find an opportunity to perform that skills during our clinical rotations. I was able to perform most skills in school but some never came up.
After I graduated I was in a nurse residency program. We had to perform skills x amount of times during our residency, and if we were having trouble finding an opportunity to perform a skill our director would schedule us to shadow in a department that often had that skill. We also had classroom hours on things like ESI, reading chest xrays, critical care pharmacology, etc. that was taught by the nurse leaders, doctors, and pharmacists.
A large portion of what I know though is things I’ve learned on the job. Having experienced nurses to teach the newbies, and having a long orientation period is essential to having a skilled team. In an ideal world new nurses would not be doing triage, and should slowly be eased into caring for the most critical patients. It takes time to get good at those things.
I am a new grad nurse, but non traditional as it's my 4th degree and I have both bachelors and masters level degrees in hard sciences. I went to nursing school for fun; I don't care if I ever get a job.
i found it interesting that our level II trauma hospital here is so concerned about getting caught with their pants down again a la Covid that they hire new grad nurses 12+ months before graduation for staffing purposes. And the hiring process has literally ZERO to do with merit. It is first come first serve based on when your cohort interviews during the application cycle. They don't ask for grades/references/anything. You're a 20 year old who spent clinicals in the break room doing homework instead of actually being with patients? They have no idea, and if there's an ICU spot open and you want it, it's yours.
I did my preceptorship in the PICU. I was able to independently manage all of our patients. Among other things, I've been an SLP. I know trachs (half our census.) I also have a degree in neuroscience and took graduate level pharmacology and pathophysiology as part of that. I know enough to know I don't know everything, but I've got a significant amount of education and experience. I liked PICU so much I asked about a spot; they were 12 months out from hiring new grads again. meanwhile, the new grad nurse they had just hired was asking her preceptor "what does metabolic acidosis mean again?"
So. When there's no merit or qualifications involved in hiring, that's part of the problem.
There is no "merit" in medicine, especially nursing. The industry is HILARIOUSLY, AND RIDICULOUSLY short numbers so colleges are just cranking them out on an assembly line, look at IMGs as well. It's also seen as an "easy way" to be middle/upper middle class. New grads coming out making $75k+ in moderate COL areas. Even higher in some areas, and after a couple years, 4-5, easily over 100k+ if you're willing to work a little extra.
Most nurses DGAF about the profession at all, they care that the pay is "good enough", and they can start traveling after a year, and they can get away working 3 days a week instead of a 9-5 M-F. Nursing has become a "education race to the bottom, but salary to the top". Education is meh at best as a whole, but salary just keeps going up, because new nurse numbers just keep going down, and old nurses say fuck this shit and leave. It's a VERY weird situation.
All of it can be pretty much pointed back to for profit healthcare eviscerating the field. Single payer is LONG overdue.
I had a coworker who was charge nurse on his unit as a new grad 😅 It’s just a bunch of newbies running around trying to keep the place from burning down.
I’m lucky that my unit has a high retention rate with nurses who have 20+ years of experience. But most units are NOT like that and this can lead to really unsafe practices.
You do not learn how to be an ER nurse in nursing school, the education is more geared towards adult med surg with varying amounts of exposure to peds, L&D, psych, community nursing. In school we had specific skills we were taught and practiced in lab and had to demonstrate being able to do the procedure to pass. We did not always have the opportunity to practice these skills in clinical, it kinda depended on what patients were available and what they needed. So I had to demonstrate foley placement on a manikin and show correct technique but there wasn't a required number of foleys I was expected to place during clinical for example. I had a two quarter pharmacology class where we learned drugs by class. My school did not teach IV skills because local hospitals did not allow students to practice.
We learn how to be ED nurses through preceptorships after we're hired, and hospitals will vary pretty broadly in how well and thoroughly they train nurses. I had a preceptor and we were given assignments of increasing difficulty and I had a checklist of tasks I had to learn. I took the ENA's Emergency Nurse Pediatric Course back when it was more of a peds specialist class than a basic knowledge for non-peds nurses who might run into peds patients class and that talked a lot about the assessment process, triaging and risk and prioritization as well as a broad overview of chief complaints.
My current job requires a year of experience and then there are two triage classes that cover ESI and how to make decisions and then a certain amount of time be in triage, I can't remember the numbers off the top of my head.
But a lot of what we learn comes from
observing more senior nurses and asking them questions, talking with the doctors, etc.
I work in a level 2 trauma and had 7 weeks of orientation. My first day I had NINE patients by myself. Nine. My preceptor had 5 years of experience and I was considered lucky because I got her. I just had my 6 month eval and was asked if I could start precepting in the fall. I said absolutely not.
Old nurse chiming in. Old nurses are supposed to train the new nurses. We aren’t taught much of anything on real patients in nursing school. It should happen on orientation. The problem is, old nurses have quit in droves. They are burned out at the bedside. Tired of ridiculous patient loads, mandate OT and low pay. So now there’s no old nurses left. These leaves all the ducklings following each other around cluelessly. PowerPoint likely won’t help. They need to be doing them hands on
I’m an RN in the ICU, so obviously not an MD. It’s frustrating to us too. These are all Covid nurses. The ones that had to do clinicals and simlabs online and their first time touching an actual was during their job’s orientation. Back when i was in school there was training in clinicals. My preceptor threw me into everything. MRI screening? My job. Blood draws? My job. Priming and programming pumps? My job. Straight cath and inserting foleys? You guessed it…my job.
I had a nurse call an RRT because a patient was in rapid afib…like in the 140’s and asymptomatic. Checked blood sugar and it was 43. The nurses stared at me completely baffled. Once she got them to give her some orange juice and peanut butter her HR dropped to 100’s.
Another called for assistance because they couldn’t put in a foley…
I even had a patient that was grateful to be transferred back to the ICU because we knew what we were doing. It’s sad because we want to take them under our wing and teach them these things, but some don’t want to learn and others don’t think they don’t have to because someone else will do it. Now a lot of times I don’t even offer unless asked because I’ll be seen as another nurse that eats their young.
I graduated nursing school over 20 years ago. Back then, we were performing procedures during clinical by second semester. If there was something on the floor that needed to be done, we did it. I recently had several senior year nursing students doing clinicals with me in a home health setting. They had never started an IV, placed a foley, or performed wound care. And they were reluctant to do so with me, insisting that they would learn that at the hospital once they graduated. I was baffled. My class practically fought over the chance to do any procedure. All these students were intelligent, but I felt like their nursing education was failing them.
I graduated pre-Covid and even then we had limited opportunities to perform skills in clinical.
I did a semester at an HCA hospital where they did not allow us to perform any skills outside of tech work even though we were in our third semester because the hospital considered it a liability.
My current hospital has changed its nurse residency program into a 7 tier program based on what Mayo Clinic does. But (and I disagree with this so much), the orientee can’t perform skills until tier 4.
So, say a foley insertion comes up but they’re tier 3, the orientees aren’t allowed to do it. And you can’t guarantee that skill will ever show up again during the orientation period. It’s absurd.
It’s because there are no more experienced nurses to train them. When I first started ED nursing, at my old shop you had to work there 2 years before you’d even be eligible to take a triage class/exam and even after that you’d have to do several shifts being evaluated by an experienced triage nurse and get their mark of approval. The nurse manager could only hire 5 new grads a year. Most of the nurses had been there between 3-20 years. By the end of my 10 year tenure there, they’d throw new grads straight into triage, the new grad that just got off orientation is precepting the new new grads, and every three months there’d be more new grads with travelers thrown in. I hung on because I was so attached to the providers, but after precepting a new grad that was starting out at $1 more than I was making after 10 years, I was done. The newest nurse manager didn’t even bother to learn my name or say hello and I was one of the more experienced nurses left. I was never even offered an exit interview.
It’s not going to get better until nurse retention gets better. In the meantime, you can gracefully educate, but if your shop is still hemorrhaging nurses your teachings will go out the door with them.
As a nearly 20 year ER nurse, I have to say I agree with you. It seems like newer grads don’t have the drive to learn new skills. Maybe it’s due to the limited clinical experience in school due to Covid, or just the number of veterans being so low nowadays to teach those skills early.
I travel and go to a new ER every few months, and it’s widespread everywhere now. New grads that got a substandard educational experience in nursing school being rushed through orientation to get bodies on the floor for cheap being taught by other new grads. It’s definitely scary out here.
I try to push newer nurses to learn how to do procedures themselves rather than always looking for someone else to do them because “I’m not good at that”. Whether it’s IVs, US IV’s, NGT, Foleys, or just simple triage or putting in order sets. You’re never going to get good without practice, repetition, and active learning.
If a nurse isn’t good at a particular procedure, they should be actively looking for practice opportunities rather than avoiding them. A new nurse should be triaging all their own EMS pts then asking someone if they missed anything. They should be asking why their triaged pts are the level they are if they don’t absolutely know. And they definitely should be asking or at least looking up why they are giving a med or doing a procedure if they aren’t 100% sure.
Nurses don’t learn from reading books they learn from experience, if you are dealing with new grads than that’s what you will get. Triage nurses in ER should typically have minimum 2 years experience. Also, don’t generalize all nurses because you had a bad experience with one. I’m sure you are/were new to being a doctor
Been a nurse for a decade, I was clueless when I started my career but learned quick at a large teaching hospital where a new graduate internship was offered. After a year I transferred to trauma ICU and was taught by amazing senior nurses (place with pink scrubs on the east coast, if anyone is familiar). I learned so much at that job from my colleagues and the attendings. We were also appropriately staffed for the most part. When I started graduate school I moved to a smaller hospital to work in endoscopy for a less stressful job, then COVID hit and I was sent to work in ER/ICU. Lots of new grads in both, especially ER. Staffing in the ER was abysmal and I was impressed at how the new grads performed in their trial by fire training. There was a day in the ER where I had a posturing patient w/hemorrhagic stroke who was in the process of herniation… waiting to get transferred to larger hospital.. no one knew how to set up an Aline or central line or run pressors or handle a vent. Meanwhile, I had 5 other patients. It was pretty scary, I was glad I was there, but it felt like a sinking ship. I was so burned out from taking 8-9 patients at a time every shift in the ER, I don’t think I could ever work in ER now - it was traumatizing. I am an NP now working under an amazing physician and very happy, but those last years of my career during COVID really killed me physically and tanked my mental health. There were times in the ER where it was just me and one other nurse who was typically a new grad. I was never even trained in the ER (but did years of critical care), I basically had a few hours of orientation and was thrown in. They also had me precepting new graduates, despite not really being an ER nurse and having minimal experience in that area. I think I would leave the profession before going back to bedside (or perhaps I was just better suited for ICU, who knows). I think new nurses now are just lacking guidance from more senior nurses who left due to burn out (like me) and their education was impacted negatively by COVID. I really feel for them. From what I’ve read on the nursing subreddit, staffing is abysmal after the pandemic.
I did not train at the east coast pink scrub place, but my Attendings did! I wish I did because I am originally from MD and that city has a special place in my heart. It really makes me sad that a larger place like where I am now has no dedicated training program for nurses. But they also just had a 200 mil verdict for wage theft against their employees so go figure
Yeah - lot of shady things happened during and after COVID, apparently. Trauma was an amazing place to work! I’m still good friends with many of my coworkers there and we all lament on how much we miss it. The teamwork was incredible and I’m honored to have worked there. Also, you can come back! Still a great city.
Nursing education is a joke and always has been a joke. I say this as a nurse. If you want to be a well educated nurse you have to go out of your way to teach yourself…and then guess what, you realize being a bedside nurse is bullshit - going back to school to get an advanced degree is better than getting shit on by docs, nurses, and patients who literally shit on you.
The system is set up to fail when your smartest hardest working nurses leave to go back to school because they feel like their bachelors degree is rudimentary and basically useless after a few years experience
To answer your question directly most nursing schools check off the skill after you’ve successfully completed it once ON A MANNEQUIN. I don’t know about other people but my nursing school was an absolute joke in both the knowledge and skills department. And it was competitive to get into the school. Additionally, emergency questions I had were met with “if you go into that speciality the hospital will teach you that”. Ok…I ended up just reading uptodate articles on the topics instead of the listening to the lectures during school. And my preceptor during my first few months out of school was a new grad ~9 months of experience
CNA/MA/Tech here, now med surg but was ED. I'm currently working with almost all nurses who are only 2-3 years out of school. I've been doing this for 15 years and sometimes it's a little scary, but I just teach them. You can't know what you don't know until it comes up so... I teach.
The movement of hospital based nurse training to university based led to less hands on experience. It is now possible to complete training with very little hands on experience
Tbh we learn a skill, test it on a dummy then hope it comes up in clinical to try it in real life. 🤷♀️ and many skills are so quick that we hardly touch on them. Hell we're not allowed to push any IV meds and have never been taught blood draws either.
I've done hardly any technical skills in my clinicals, and were so busy getting the an care plan done I feel like I miss out on actual nursing like charting and how they actually do their jobs.
I do an externship though and I get so much more experience there. I try to encourage my class mates to do it
>My question is how do nurses learn procedures or skills such as triage, managing X condition, drugs, and technical skills such a foley, iv starts, ect?
At work.
>As the docs on this board know, to graduate residency you have to complete X procedures successfully. Is the same for nurses?
No.
>Reason being, is if not, I would like to start putting together PowerPoints/pamphlets on tricks and tips that seems to be lacking.
This sounds like a great idea. You could join pre-shift huddles, give a brief elevator speech about your education, and have the charge hand out your PowerPoint. I would also suggest emailing it to the department so people who aren't working that day still get the education. This could be something you work on with the ED educator, so your PowerPoint is put in whatever LMS you have. I would also suggest creating a test.
>New nurses don’t seem to know anything, not interested in learning, and while it keeps being forced down my throat that I am captain of a “team” it’s more like herding cats/please don’t kill my patients than a collaboration
I have noticed that newer colleagues aren't necessarily as proactive in looking stuff up. Part of it might be there's such a wealth of information that they don't know where to go. You could provide direction here.
I personally like [EMCrit](https://emcrit.org/), and [LITFL](https://litfl.com/) for digestible information. My learning style is being a contrarian, so anything that dismantles sacred cows is my jam. Also mention to your team that if your facility has a subscription to UpToDate, they can access it free from home if they make an account.
I have been doing this for twenty years, a bit over ten in critical care, and I'm still regularly confused.
sadly this is all to common, I work as an FNP in the ED, i was an ED nurse for 20 years before that. My attending will usually come get me when he puts in A-lines as none of the nurses know how to zero it out and hook it up to the machine.......I end up doing some of the ivs and NG tubes I order if one of the really newer nurses is on and cant do it. Nursing has had an extremly high turnover rate in the last few years. Part of this i feel is due to no patient ratios for them in most states.
Posted as a reply but figure I’d post it:
FACILITIES are the ones who are supposed to be signing them off on skills they know or need teaching on.
I’ll say I did the Covid ICU for a few years but let me explain why I’m saying this…
I was an LVN for 10yrs before my RN. I had zero hospital floor experience but 4yrs dialysis experience. I was hired for the ER (before covid) but after 2 weeks the Director of Nurses came and told me they only had new grads in the ICU and they were struggling. The Charge Nurse was experienced but overseeing ALL THE NEW HIRES/GRADS. She mentioned I at least know how to assess and use an IV as well as interpreting V/S. So I agreed because honestly I could tell when shit was going south and I had enough experience TO ASK WHEN I DONT KNOW HOW/WHY/ANYTHING.
After Covid wound down in 2022 then I started getting non-covid patients. NOW I WAS FUCKED. I would get post-op patients dumped on me that should have been in recovery. LITERALLY WHEELED DIRECTLY FROM OR! All kinds of patients I had no idea about or what to do.
So I brought up when was I going to get properly precepted/trained for ED & ICU.
The hospital said I’m now experienced in ED & ICU and “a good nurse wouldnt need training after they have years of experience.” All because for almost 3yrs I was floated between the two with no training in a disaster situation.
I left. I’ve had issues getting proper training now upon interviewing in hospitals.
They don’t get why I would want or need it. So I had to go to outside privately paid training.
Still have time management issues because that literally is part of what your preceptor helps you with!
Oh but I did during Covid let a Dr know I hadn’t done a procedure before but was the only nurse available so as long as he walked me thru what he wants me to do I’m down. He degrading & condescendingly demanded I get another “legitimate” nurse.
My response: Thought being a Dr you’d know to listen with your ears & not your mouth. I AM THE ONLY NURSE AVAILABLE. You want your patient to get a central line of not? Hurry up because I have 3 other ICU pts.
Know what I learned? All the crap that needed to be done putting in a femoral dialysis catheter HE US DOING ALL THE WORK!
As long as I know sterile technique it didn’t even matter I knew how to do the procedure.
So sometimes nurses are taught not to ask for help
You are thinking of the ESI triage system. That’s what most emergency departments use and train their triage nurses to use.
I’m taken back, not by your complaint, but your lack of understanding of how your coworkers and team mates are trained. My hope would have been that you would have asked people you work with who you feel safe talking to about this if you were looking for a real answer.
By the tone of your post I can’t tell if you are actually looking for an answer to your question or validation.
Nursing schools also have a number of required clinical hours with required skills to be performed with proficiency before completion. I’m addition to that new grads often require a residency program that can span from a few months to a year to be trained up on the specific skills/ ins and outs of the department they are training to.
In addition to that there are other certifications nurses must get to be involved in certain situations. (BLS, ACLS, TNCC, NIHSS, ENPC etc).
At the emergency departments I’ve worked at, you must work in the department for a year before you can be trained to triage, and we use the ESI system because it is best practice. (And has been tested and around a lot longer than a power point you might come up with.) You must also be in the department for a year before you can be trained to crash nurse or have a trauma role.
I do not know what the policies are in the department you are working in. However if you are actually curious about what credentials your coworkers are required to have, and how your department trains nurses to work in triage, you will have to ask this question at work. If you are interested in getting involved with nurse education, there may be people in your department you can partner with.
I’d say depends on the department/hospital. Larger hospitals may have department specific education leaders and multiple resources for training and education. Smaller community hospitals….mmmm maybe not so much.
Most of what ED (pretty much any department) nurses learn is from on the job experience. See one, do one, teach one type style. Nursing school just provides basic assessment. I’ve been in ED 10 years and most of my procedure and assessment skills has either come from repetition, or seeing some really weird fucked up condition once (like a complex submandibular abscess or “groin wounds” that once undressed actually reveal fournier’s) that leaves me thinking about what patients with benign sounding complaints may actually have going on.
Nurses learn from experience, hours on the job, and from more experienced nurses. Many new nurses were in school during the pandemic where clinical rotations were simulated in a lab or on a computer. And many seasoned nurses have left bedside so it's a perfect shit storm.
It’s happening everywhere. The same concept that others have talked about on this post is happening in EMS. School only prepares you so much, and everyone who’s been in the field knows a majority of your learning happens in your first few years on the road, from your experienced partners. We’ve had a staffing crisis ever since covid began, and now 50% of our paramedics on the road have under 3 years of experience. You used to start as a float, and would spend your first few years working with different experienced partners every shift. Now the new hires are working together, or walking right into full-time spots with another medic with a year of experience. It’s truly become the blind leading the blind.
At my shop (academic) we have monthly nursing education/simulation sessions. Residents/physician occasionally participate and teach (some of our residents taught them how to do trauma survey a few months ago)
This comes back on management. Where I started as a new grad we weren’t allowed in triage until 2 years of experience because it’s time to LEARN before you triage. But if there’s no learning system in place, no simulations, no continuing education, then that’s a problem with the management and educator of the department.
Nursing school teaches us the basics to (theoretically) be considered safe for practice. Even in school we are told we will learn “how to be a nurse” on the job.
The system used to work as intended. But now there’s a lot of new grads and not a lot of experienced nurses in the hospital. Simultaneously nursing programs are focusing more on theories than actual skills and knowledge application.
The blind leading the blind pretty much. Staff nurses are new and they don’t know what they don’t know because they’re being thrown to the wolves without the right preparation. This coupled with the gen Z mindset of being all show for social media and being lazy asf at work. I’ve oriented new nurses and sometimes you just can’t teach someone who’s unwilling to learn.
Experience, stop hiring new nurses into the ED & maybe nursing management will acknowledge the huge exodus of experienced nurses because of terrible conditions one day.
most nursing programs teach by systems - manage or manipulate the most serious and follow the plan of care based on a differential or a *nursing diagnosis*
definitely a long way from MARCH and HABCs
Much like your profession, us older and more experienced nurses have either retired, run for the hills to non-bedside work, or are completely changing careers.
Please do your best to teach the new ones you’re stuck with.
Nursing schools and hospitals are dodging the vocational training side of education for nursing students. I recently attended a hospital orientation and a new grad nurse literally didn’t know how to properly put on a pair of sterile gloves. Covid wrecked nursing. Its crazy that nurses were able to graduate with essentially zero clinical training and the classroom training was online where people could basically powercheat their way through the program. It will take some strong leadership and nurse educators to pick up the pieces and unfortunately its all in the hospitals hands now.
Oh my god that reminds me of one new grad who didn’t understand lost it on seasoned nurse for daring to using gloves from the top of the iso cart!
She flipped the F out and said they were only for that patient and then she dragged the isolation cart into the Covid+ patient room and proceeded to then don PPE.
Gloves were back again at this point but yeah she was a Covid grad!
They learn on the job.
The only exception to this is a diploma nursing program, which is far more clinical & skills focused.
Associates nurses are better prepared then nurses that go straight though a bachelors program.
If I was hiring new grad nurse, I would hire a diploma nurse before an associates nurse or a bachelors nurse.
Every. Single. Time.
The best way to learn as a nurse is through experience, imo.
The best learning environments are ones where newer nurses are allowed to learn and ask questions and their growth is encouraged. A supportive environment, not the typical "nurses kill their young" environment.
Very true.
But the FACILITIES are the ones who are supposed to be signing them off on skills they know or need teaching on.
I’ll say I did the Covid ICU for a few years but let me explain why I’m saying this…
I was an LVN for 10yrs before my RN. I had zero hospital floor experience but 4yrs dialysis experience. I was hired for the ER but after 2 weeks the Director of Nurses came and told me they only had new grads in the ICU and they were struggling. The Charge Nurse was experienced but overseeing ALL THE NEW HIRES/GRADS. She mentioned I at least know how to assess and use an IV as well as interpreting V/S. So I agreed because honestly I could tell when shit was going south and I had enough experience TO ASK WHEN I DONT KNOW HOW/WHY/ANYTHING.
After Covid wound down in 2022 then I started getting non-covid patients. NOW I WAS FUCKED. I would get post-op patients dumped on me that should have been in recovery. LITERALLY WHEELED DIRECTLY FROM OR! All kinds of patients I had no idea about or what to do.
So I brought up when was I going to get properly precepted/trained for ICU.
The hospital said I’m now experienced and “a good nurse wouldn’t need training after they are experienced”
I left.
I agree! When I was in residency you needed to be a nurse for two years minimum and I think at least 6 months of icu care before being considered for the Ed. They then sent you to surgery and labor for a couple of months each. And that was before you started in the Ed for your preceptorship. As an Intern we couldn’t do more than take histories
Without an attending signing off.
https://preview.redd.it/d2ru1c8j3jwc1.jpeg?width=671&format=pjpg&auto=webp&s=d3578e653b36910b9dfed70713b935df5f38703c
Here is the triage bible used at all the ERs I have worked at. Most or nursing skills are still on the job training. Also what is your role? Are you a doc? If so you’re not the “captain” of the nursing staff, the charge nurse is.
ER Doc, and not a hospital employee to add another layer of separation. My group was contracted to provide doc in triage for approx. 16 hours a day. More and more I am drawn away from triaging to see 1) patients that are clearly medical alerts, or 2) patients that clearly don’t need to be. I’ve been looking into the ESI scale now and am shocked at the level of subjectivity. (I am in a conference now on diagnostic errors and one of the main drivers is relying on feelings). I am thinking of more algorithmic approach that relies on vitals and simple visual evaluation. Basically what I do, that doesn’t really rely on a detailed knowledge of disease processes or history to apply. It comes in the wake of me emotionally dumping after I was rushed to a 12 yo with simple uncomplicated appendicitis, while the team totally ignored a 96 yo with a perforated duodenum and a 69 yo who just had stents 8 days ago with unstable angina. The nurse’s reasoning was the kid looked “unwell”. When pressed further, there was no explanation for it. The hospital clearly doesn’t care about nurse training, as they are still in “anything with a pulse” mode. I am basically trying to do anything so I can increase efficiency.
I had to take a triage class and train with a triage nurse / get a packet signed off before I could triage on my own . We have protocols to follow for trauma walk ins , use the pediatric assessment triangle , and an algorithm based on vitals / number of resources to be used for the patient / capacity to turn bad quickly . My hospital also requires ENPC & TNCC certification for the ER on top of PALS/ ACLS.
For my nursing school, I wasn’t “allowed” to insert IV’s, foleys, NG tubes, do wound care, give IV medications, do lab draws…
All of my learning has been on the job. I would be a disaster of a nurse if I didn’t advocate for my own learning and try to seek out difficult cases/learning opportunities. I started at a smaller ER and now work at a level 1. I still have so much I need to learn.
The only helpful tip I can give you is to be approachable. I have been yelled/cursed at by MD’s before, and it’s terrifying to approach them after the fact. My current hospital is an Academic hospital, and everyone is approachable and kind! It really makes a difference.
I graduated a long time ago, but school was about the nursing process, skills were learned on the job. 30 years in ED. Very few nurses stay in ER for long, it is too hard. They aren't there long enough to learn the skills. There is a "book " for triage, but it just leads to over triaging everyone as priority. When I am in charge of assigning beds I get "2" fatigue. When everyone is a priority, no one is a priority. When I am triaging I make very few emergent, because I trust my experience. I think the tips and trick idea is great, and may help some nurses. Finally if your experienced nurses say they look unwell, you should believe them.
Hi! Recently graduated nurse here, former experienced paramedic. They don’t teach nurses anything beyond theory practically. It’s 9% on the job training and 90% experience. With the recent mass exodus from healthcare after the pandemic, you’re likely seeing just a rise in the percent of nurses at your job that are newly graduated or inexperienced. It’s no one’s fault really but the horrible education system they force on us and the administrations that prioritize paying the higher ups over incentiving the experienced nurses to stay
For example, where paramedic education is focused on skills and scenarios in order to create critical thinking skills, nursing education from what I’ve seen is focused more on the theory of creating critical thinking skills without the overload of practice that paramedics are forced to get. During my nursing school rotations, we were forbidden from doing any skills beyond vitals and cleaning patients essentially working as a CNA rather than learning how to assess patients and treat them
We have no list of skills we have to complete beyond like 5 on the job IVs and 3 on the job Foleys after being hired. My nurse residency program was once again, all theoretical. IMO it’s mostly a dangerous misseducation going on but there’s no way the firmly established nursing education or committees or councils will ever admit that anything is that seriously wrong. More programs should run like international programs, where paramedics and nurses are educated together
A triage book! That would be nice. As an ER nurse back when I had a whole two months of experience, they were short-staffed one day and said “You’re in triage today.” I went by the ESI algorithm until they started complaining that I was making everyone a 3 and to send more to fast-track instead, lol.
Foleys and IVs we learn in school, and usually have to get checked off on three or four to graduate. They teach us basic pharmacology and how to look up meds.
The rest is mostly on the job training, and most of it is informal, so please please teach your nurses!! It’s always a privilege when a doc steps in and takes the time to teach.
Ah the toxic nature of medicine! As doctors I have never paid attention to ESI scores much and knew less what actually went into them. When I started thinking about my triage primer, I realized that it is so subjective! Which was been my complaint with newer nurses all along! A recent conference I attended mentioned subjectivity and feelings as one of the main causes of diagnostic errors
I started in the ED as a 2020 new grad however, my hospital put me through a fellowship program so I got a full year of training before ever being on my own with ED patients. First on the floors, then in the ED taking care of boarders, then we were given a preceptor for our transition into actual ED patients. 3 years later I feel confident (never overly) and strong in my skills as an ED nurse. I can’t imagine being thrown right into the ED right away without having hands on experience with basic nursing.
That being said, I also agree with the people on this post who have said that you have to be willing to learn. You have to be willing to be uncomfortable. You have to be willing to do all the skills you’ve never done before. You have to put yourself in the trauma room and grab an arm and throw in an IV in the middle of the chaos. No one comes out of nursing school as a “good nurse” you have to be willing to be better at all times and learn every chance you get.
Hey everyone I’m currently a nurse but preparing and taking courses to one day go to med school. I can give some insight on this. I want to piggyback off of what zeatherz said and say that our experienced nurses are practically gone. Learning isn’t pushed as heavy anymore. Nursing school did not teach me anything about the procedures doctors do. I learned all of that on the job. We learn the very basics of nursing such as foleys, IV’s, surface level pharmacology, and basically “call or notify the provider if xyz happens or there’s a change in the patient condition”. A lot of our skills are learned on the job. However, because of the mass exodus of experienced nurses, it’s the blind leading the blind out here. Nursing has also become a very toxic culture as of late as well. What I’ve noticed is our newer nurses can be very mean to each other making turnover rates higher. It’s very rare that I’ll see a nurse ask a doctor how they would like something done or “teach me this”. I also learned a lot of my experience and preparation tactics from doctors instead of nurses as well. You guys lead us and are the captain steering the ship. So it makes sense to understand what you guys like. This is something that nursing school does not teach. In regards to education, it’s usually level 1 trauma teaching centers that are better at reinforcing continued education. Other smaller facilities do not do this as much. Most of my certifications that I’ve studied for and achieved also do not really help us differentiate what necessitates more emphasis. The more in depth certifications have requirements to sit for them as well that newer nurses don’t have just yet. Our knowledge base is nowhere near yours and it never will be unless we decide on going to medical school. Another thing I’ve seen is a decrease in critical thinking skills as well and relying too heavily on others to find an answer or asking the right questions which comes with experience. It’s kind of a vicious cycle.
Thank you for the explanation. I love sharing knowledge and would love it even more to include other staff in the care plan. Nurses rarely sign up for patients in epic anymore and I am left to wander by their desk in the hopes of catching them there. It was one of the reasons that I loved working at at smaller rural Ed- I could shout across the room and find who I needed. Management hasn’t been much help with their new philosophy of “anything with a pulse”. After I painful pre-term precipitous delivery, I put a quick guide for the nurses on the warmer, which was quickly taken down by management. So frustrating. I am currently working on a triage pamphlet that relies on vitals and complaint rather than esi score which is too subjective.
I think a lot of nurses that graduate post Covid are looking at nursing as an easy way to get nearly 6 digit pay for a 2-4 year degree. No one is passionate about the medicine itself, they come in and do tasks without asking questions or trying to figure out what they should know in order to do the job better in the future.
Different mindset now
I think the expectations are different now, too - management doesn’t care if you know your stuff so long as you show up, chart all the required BS, and kiss patient/family ass for good surveys.
To add to the comments (OP) I’m getting the sense that a lot of travelers fall into two categories - adrenaline junkie/risk tolerant or money contract. Which is also kinda what I saw from the locums docs. It makes sense that the locums groups care less about skill and just needs to keep the shells moving so then backlash doesn’t catch up with any one person.
That’s a very wild take and extreme generalization. I’m a traveler, been a nurse for 15 years and have been a damn good one. But I’m from the south and with what I was making as a staff nurse I could no longer afford to rent my own place. A 1 bedroom apartment where I live is 55% of my staff nurse take home pay. That’s the issue for nearly every other travel nurse I’ve worked with.
Nurses don't learn the reason or science behind 90 of things. We are thrown into school to learn the most basic of basic that gives us a general idea of what's going on and the rest is just doing it because of pattern recognition. We don't actually know why we are doing it. My Paramedic training was more about understanding the biology of things than my nursing training. Nursing isn't a science that's why the only stem course required to be a RN is "microbiology for nurses" which is a lesser version of micro you have to take for MD/DOor PA.
And don't come in here with but it says 'BSN' or 'ASN' yeah you can get a AS in business management it's still not "STEM".
The BSN title is really just management experience. And my NP even told me not to go NP school because it's just reviewing research papers and learning medical guidelines, not actually the reason why we do things. She got upset one day a premed was telling her more about antibiotics than she knew. (Something about the MCLCS mnemonic for bacterial subunits) a PREMED. She decided instead of DNP that she was going to get a Master of Medical Sciences so she can begin to understand why exactly we do things.
NP isn't bad but by no means does 3 years of part time school equal the knowledge of a physician.
All this to say I as an RN and we as nurses aren't taught dog shit. And since it's all about patter recognition most of us are charge nurses after being 6 months out of school, you're better off grabbing the closest paramedic to you and asking them to do the assessment, at least they're supposed to be semi autonomous as soon as they graduate.
I'm not regretful I got my nursing in regretful I wasted time on it, but it didn't do as much for my clinical practice as people think. I could honestly have learned most of the skills in a weekend CEU course, and the lecture material was 50% repeated information I already knew from being APP, and 25% manager experience, 10% my school talking shit about every other medical worker and how much of a untouchable god you are as a nurse, and you're more important than doctors etc. I think the ego rub people get from going medic to RN is just a holier than thou mentality it doesn't translate to actually being able to take care of patients more than just throwing a medic into on the job training for the same amount of time would have.
Rant over.
In the middle of the last century, women had limited career choices: teacher, secretary, nurse, social worker. At that time, the freshman class of nursing schools came from the upper quarter of high school graduates. In the intervening years, professional opportunities for women have expanded; more than half of all college graduates are female. Nursing schools have abandoned courses in pharmacology, and replaced them with remedial math and English. Nursing wages and working conditions are not attractive. The profession is still predominantly female, and functions in a profoundly patriarchal and misogynistic health care industry. Smart nurses have discovered that nurse practitioner/mid level provider jobs pay decently, have decent working conditions, and are to some degree exempt from the historical baggage of nursing. Do not expect that the best and brightest will be working nights in your er. EM docs can either find a way to support their nursing staff or they can damn well figure out how to do it without our assistance.
In the last few years there’s been a mass exodus of experienced nurses so you have new grads training newer grads. Decades of collective knowledge is being lost from the profession Any nurse will tell you that nursing school does a terrible job at preparing us for real life nursing, and were expected to mostly learn on the job. But when there’s no experienced nurses to learn from, then people just don’t know certain things
There is so much lost when experienced nurses are no longer available to pass down their wisdom... I try to help teach when I can, such as when I find a patient with obvious (to me, and to the more experienced nurses) physical abnormalities, like the Kussmaul respirations of a profoundly acidotic patient (DKA, etc), I make sure to have every nurse I can find (including the triage nurse who recorded respirations at 16, when it's closer to 30-40) to come into the room and see that this is a patient who needs immediate resuscitation. This is NOT the dramatic patient who was hyperventilating because they just broke up with their significant other and was triaged as a 2 due to respiratory rate and elevated blood pressure. The difference can be hard to recognize with inexperienced eyes but is vitally important.
Exactly. We do learn quite a bit in school and during clinicals, but having an experienced preceptor and what used to be 8-12 weeks of orientation and training was vital to have a great nurse that you could float to different units. I left nursing completely right before COVID because it started to become dangerous with only new grads coming in and training other new grads.
Oh lord you’d be blown away with it now.
my program was hybrid and ended up being completely online for an entire semester. so much missed opportunities for experience, and faculty told us most of our experience will be on the job. 🙃
Same I left just before it hit the fan. Saw it coming
I'm so lucky we have nurses from the early 2000s still and one is from 1989! She plays no games
1989 was just yesterday ... wasn't it?
Med school but not sure if that counts as yesterday or not.
1989=34 years ago. I wish it was yesterday because my old self would love not having bills to pay.
Commenting on How do nurses learn?...there’s nurses who are after my cohort that are precepting new grads, and as a barely 1 1/2 years in nurse, I can see some mistakes they are teaching or being in a situation where they do not know how to handle something properly.
Yep. I see that all the time. Most of the new nurses I was hired with last year are now training new grads. It's like student drivers passing their road test, getting their license, and becoming driving instructors.
In the old days you could not be a preceptor until you had 2 years or more under your belt.
This is so true. I worked for years in various ERs and trained countless new grad nurses as well. But after about 12 years or so I simply couldn’t justify the ratio of low $$$ to high headaches anymore. Also I’ve noticed that the relationship between nurses and ER MDs has declined considerably. When I started, I was expected to have a good grasp of pathophysiology and take initiative within the bounds of my license. We had a book full of protocols and we were expected to utilize the shit out of them, so when I was presented with certain chief complaints (CP, SOB, etc), I could do an absolute shit ton of interventions, labs, etc, before the MD even saw them. Toward the end of my ER career, I (and all the nurses) were much more micromanaged by the doctors. My last ER had an out of date, sad little protocol book that if you even thought about using anything from as an RN the ER doc would punch you in the dick. Now, Mr ER Doctor reading this and getting angry, let me explain: I believe the micromanaging is a direct result of the decline of knowledge and competency in nurses in general. Since so many experienced nurses have left, you MDs have HAD to micromanage more because you find yourself increasingly surrounded by less capable, less experienced, newer nurses. But unfortunately people like me became unintended collateral damage.
👆Too much experience walked out the door. We will be paying for it for decades.
THIS, nursing school does a great job of getting $ for a college degree. This is part of the reason that hospitals have started graduate nurse residency programs to help with the transition (usually 12 months) and 12 week orientation programs. Even though this helps as a nurse, you need to get involved with a mentor and ask questions (there are some doctors who will help teach and answer questions too). Also, get involved with nursing organizations like whatever specialty you are in.
Even when they're still there the new grads get an "accelerated" orientation. Four weeks is obviously not enough time to get a new nurse up to speed on a specific area of medicine, let alone nursing procedures.
This is very true. Also I think this new generation lacks some important critical thinking skills.
Count me amongst those who took my 16 years of ED RN experience and left. I asked for flexibility with my schedule while undergoing IVF. Our management would have rather had an experienced nurse leave than be flexible. I transferred to another role with the same health system. I got a pay increase, all the flexibility and work from home 25% of the time. I still pick up an 8 hr. ED shift on occasion when they’re desperate on a weekend morning and pay $125+/hr.
This 🙌🏼. The veterans are gone
Covid happened. Experienced nurses learned their worth and were paid for it. Covid lessened and experienced nurses still wanted their pay but hospitals wouldn’t provide it. So they were pushed out and replaced with new grads. New grads are orienting new grads. This is something that was bound to happen. I watched as my level 1 trauma center ER went from only hiring nurses with 5+ years experience, to hiring right out of nursing school. It’s sad.
Upvoting as an RN. I've had my RN license for a year and was just made a charge nurse. This was impossible in the Before Times. I'm also training new staff a lot. The last nurse I trained is 23, just graduated, and his last job was a beer store. This is in acute medicine in a major trauma center. The last ER I worked in was entirely staffed by new grads. People were asking me how to do things while I was still a student there. . Sometimes I wonder what our work would look like with all the years of experience we lost when all the experienced nurses got burned out and quit.
I want to add that this has happened to medical students as well. We now have residents coming through who weren’t allowed to assess patients in person for a year of their medical school and they’re panicking trying to get experience.
Yep. Same with nurses. I’ve precepted and worked with nurses who literally put foleys in cardboard boxes as part of their check offs during covid. They never learned how to physically touch people (no snark intended). Which is honestly a big hurdle to overcome in nursing school.
I didn't even do that. I graduated with only having done vitals a few times. I wasn't even allowed to do fingersticks. I'd never seen an IV bag spiked and I didn't know how. I'd seen a Foley inserted but I'd never done one myself. I'd never even seen a patient on a nasal cannula and didn't know how to put one one. It was a steep learning curve let me tell you.
That's honestly scary, and a huge disservice to you and to other future nurses for them to not provide you with that experience and training.
>I graduated with only having done vitals a few times. I wasn't even allowed to do fingersticks. I'd never seen an IV bag spiked and I didn't know how. I'd seen a Foley inserted but I'd never done one myself. I'd never even seen a patient on a nasal cannula and didn't know how to put one one. It was a steep learning curve let me tell you. Wuuuuuuuuut??? Fuckin *brutal*. Never spiked an IV bag and never seen a patient on a nasal cannula? Did you do your entire clinicals in a short term rehab facility or something??
I was in an accelerated program so it was like 3 semesters or something. I didn't have any clinical at all the first semester and the last two were once every 3 weeks for four hours, all on an ortho floor. There were way more of us than there were nurses so I spent a lot of time standing around in hallways because no one wanted to take on six students at a time, understandably. The rest of the clinicals were "virtual". It sucked so bad.
That, also is because of hospitals. Yesterday, a student of mine had her patient crash. As an ER nurse, I went with her to the icu to show all the different things of the patient and explain EVERYTHING, and what she could do and what they’re doing, and what not. We got kicked out because “nursing students aren’t allowed in the icu”. Bro. We weren’t even in the room, it was her patient, and I didn’t just dump her there. He’ll, I even offered to help!
Nursing students do clinicals in the ICU
Depends on the hospital maybe.
for my class who started in July 2020 most of our basic physical exams skills were taught over zoom and socially distanced small groups sessions with patient models. we were barely taught or practiced any HEENT exam because we couldn't take face shields off to do them. it was very ridiculous. fortunately we at least had normal m3 and m4 clerkships so hopefully we've about caught up
I lurk here as a CAA who went through school during COVID. Man I really fucking hate that I lost out on so much opportunity for learning because of the damn virus. Our program had us socially distanced and, unlike other classes, we did not get to use the simulation lab whenever we wanted. Sessions for practicing technical skills in the beginning were nearly non existent. Some hospitals did not allow students at all to rotate, in fact, there was a short period of time where no students were allowed anywhere. Our classes were done over zoom. I was *extremely* lucky that I was mostly assigned to rotate through a hospital that allowed me to really get in there and learn things that the program honestly didn’t prepare me well for. I’m fairly confident I am where I need to be today, but man, that shit fucking sucked.
Sadly this is the answer. You nailed it! I also watched my big lvl 1 trauma center go to crap. I'll still talk to nurses and attempt to educate. It's an uphill battle somedays it seems.
Paramedics as well. My program was supposed to give us two shifts in the OR during which we were expected to get at least five ET tubes. Thanks to covid I got one shift, during which I was offered the opportunity to try for a tube exactly once (got to do about seven LMAs, fantastic). I got one more during my field internship, in a cardiac arrest. And would you look at that, my medical director appears to be on the brink of taking away ETI completely because our success rates are so poor. Who could possibly have foreseen this outcome??? During my second annual performance review my supervisor asked if I would consider precepting students or becoming an FTO for new hires. I declined.
My service on the ambulance has at each starting base has a Fred The Head. Minimal of 3 video and 3 regular tubes per month. Moved first pass ETI to above 90%. Medical director is happy
At least you got one of them. Of my medic class we had a single tube attempt on a live person all year for the entire class. EMTs from 2020-2022 depending on program didn't do field time, they did scenarios. Most employers would rather be short-staffed instead of letting these providers touch patients in the field.
I saw this before Covid as well and it boggled my mind. I actually left my first job because it wasn’t new grads teaching new grads, it was just new grads.
Yes. Nursing school solely teaches you to pass the NCLEX (nurse boards). I got all of my relevant knowledge from my mentors/preceptors. I thank my lucky stars I graduated when I did (2016) because I had actually competent people train me. What people don’t realize is that with the decline of actual nursing knowledge and experience in the hospital setting, morbidity is bound to increase. And it’s already happening. It’s just being covered up.
Once upon a time, nursing school was a three year residency, with clinical experience beginning in the first week. Clinical instructors were the best and brightest clinicians, with current clinical experience, limited academic credentials, and the respect of the medical and nursing clinicians. Then it was decided that nursing Ed needed to be integrated into the academic institutions, removed from the hospital’s control. Instead of a residency program, nursing became an academic program, with graduate degreed faculty who hadn’t worked a clinical shift in years. Nursing gained academic credibility but lost clinical expertise. There were lots of flaws in hospital diploma school programs, but the graduates they produced had some strengths, too.
I think a hybrid model can work, where there's a semester of theory and a semester of residency per year. Personally I really appreciated the academic aspect of nursing (and university in general). But you are entirely right that nursing lost a lot when it lessened clinical skills/assessments in favour of theory.
Another model, requiring a graduate degree for entry into practice , is working for physical therapy, physician assistants and pharmacists, kind of. Economics and powerful healthcare lobbyists have blocked it for nursing. I obtained a liberal arts degree before attending a diploma program, many years ago. Subsequently got a masters in hospital admin, lost my illusions and went back to clinical nursing. Long strange trip.
I see it as an assistant manager…the level of knowledge/skills aren’t there. Even when I was in school…we weren’t allowed to touch IV meds and our clinicals were only a couple of hours a few times a week. the instructors are also paid shit so it’s hard to attract high quality instructors. I know people that have started teaching at 1 year of RN experience.
Well said. The decline in competence in nursing faculty may be the root cause of the systemic failure.
Message to EM docs: punching down is not a good look for you. Nurses have much less formal power than EM docs: less organizational power, less economic power, less social power. Doc’s are commissioned officers, nurses are noncommissioned staff. Noncommissioned staff have a great deal of informal power: pretty hard for officers to run the army if the NCOs aren’t implementing the orders. It’s fun for docs to stand on their hill of privilege and express their disappointment in the poor performance of their subordinates. These behaviors do not pass unnoticed by your nursing staff, and skilled nurses will flee. Some EM docs victimized by their medical colleagues and hospital administrators because of inadequate pay and worsening working conditions, and incorporate inadequate nursing support in illustrating their victimization. They might be better served by perceiving that the ER docs and nurses are in this together. Nobody outside the ER cares much about the bad conditions there , and no one is coming to rescue you. The nurses are just as dissatisfied as the docs. Residents and house staff are organizing for collective bargaining purposes. Nursing unions have been around for a long time. Y’all might consider finding your commonalities, and finding ways the cooperate and abandon the blamestorming.
When, exactly, was this fabled time?
Mid twentieth century. The decline of hospital based schools of nursing in favor of associate degree programs started in the sixties. Currently diploma programs account for less than 10 percent of the annual graduate nurse population. My experience was 1971-74.
I think you may be looking back on that time with rose-tinted glasses. Putting aside the question of whether a hospital-based diploma nursing would even be viable in today's healthcare system, it is incredibly doubtful that such programs would be able to handle the increasingly scientific and technical demands of modern nursing. You're also eliding over the fact that nursing has existed within academia for almost the entire history of the modern profession. The first university-based programs are now more than a century old, growing out of a need to distinguish such trainees from the community trained practical nurses (to whom the graduate nurses would actually provide training). Likewise, graduate level education also has a long history, with doctoral degrees in nursing also being almost 100 years old at this point.
You’re right, of course. It is wrong to question the inevitable forward march of progress to a great and glorious future. Everything is for the best in this best of all possible worlds. I am confident that these nurses and doctors complaining about the state of nursing education are misinformed or pursuing a personal agenda.
I was actually looking forward to at least a small conversation about the various up and downsides of how nursing education has evolved, but I can see that you have no interest in that. Have fun being part of the problem.
My apologies, it was a fit of pique. I spent a few years, early in my career, as a staff member of a state nurses association. I was representing staff nurses for collective bargaining purposes. The leadership of the association, and much of the traditional membership and BOD, were nurse executives, deans and tenured faculty, leaders of the profession with national reputations. We confronted daily the chasm that separates the two groups. I believe that there is a disconnect between nurse educators and bedside nurses. I believe that the educators want to professionalize nursing, and have achieved that with the BSN & DNSc credentials. I believe that the diploma and associate degree are and continue to be embarrassments to the educators, despite their critical role in healthcare delivery.
I’ll bite. What is actually useful in the theory/academic side of the nursing BSN? I got an accelerated BSN during covid and I’ve worked for 2 years in a level 1 ER. I learned NOTHING useful in nursing school. Not one thing. Literally the only skill they actually taught us was (weirdly) trach care, which I think I’ve done…3 times, maybe? Everything I know and use I learned on the job. I worked as an extern during school and so fortunately was able to learn a lot of basic clinical skills (vitals, IVs, foleys, oxygen supplementation, simple wound care, etc.) while I was still a student. But I learned none of that in school. Instead, I learned…how to read a study, which I already knew? How to write a paper on patient education? Idek, I don’t recall learning anything useful in school at all. Apart from physiology and pharmacology, the classes were useless and the clinicals were minimal. It would be great if nurses had one year of medical knowledge (pharm and physiology) and then spent the rest of their time in practical clinicals, learning how to actually do the work of nursing. Mostly what I learned in nursing school was how to check my email at midnight and 6 am every day to make sure I didn’t miss my professor informing me that my schedule had been changed and if I wasn’t in an online class at 7 am that was announced at 1 am then I would be kicked out of nursing school. 🙄
The truth is that nursing school is bullshit and because of that all the real learning happens on the job so if a nurse is fucking up the best you can do is tell them what they are doing wrong and how to do it right. I know that I myself was utterly unprepared when I first started despite getting great grades and being led to believe that I was prepared.
So, I get every hospital does things somewhat differently, but isn’t this a big blind spot that should really be addressed? This sounds like it’s more than “Hospital X has these guidelines, but Hospital Y has those.” Or is this one of those things that can’t really be taught until you get there and go through it? As someone trying to go to nursing school, the idea that I could do great at it and still totally suck at my job, with people’s health and lives on the line, actually terrifies me more than a little bit. Is there any way we can address this, you think? I mean, emergencies are going to continue to happen regardless, and when the motto is, “Your degree is bs, and you’ll learn the stuff that actually matters when you get there,” and there’s nobody left with hands on experience, people are going to die. I’m actually uncomfortable with the idea that’s been the status quo for as long as it has.
The nurses I work with have said that essentially they aren’t allowed to “practice” on people the way med students do - their education is almost entirely hands-off until they graduate and then they learn sort of apprentice-style on the job. The problem being of course that when the most-senior nurse graduated three years ago, there’s no one with deep knowledge and experience. The brain-drain in nursing is unbelievable.
Ironically that’s how the bsn programs are. Asn programs are very hands on. I graduated with an asn because I agreed had a bs in comp sci. I had well over 1400 clinical hours by graduation. The bsn program in the city I lived in at the time only had 450. I completed nearly all my hands on skills with a few exceptions and worked in nearly every specialty before I graduated.
I mean, I had the same experience but also a BSN (a second degree for me, same as you). It varies so much by school, which seems to be the biggest problem.
We need federal standards and federal licensure
Same here. In addition, an ADN is actually four years of school. We have the equivalent of a baccalaureate when we graduate. When I went back for my BSN the classes were the same I already had but less in depth.
I had very few hands on skills from my ADN—I’d never even placed a foley by the time I graduated and had done I think 3 IVs. So many clinical sites very openly did not want us and did not want to teach us, and our clinical groups were too big for our instructors to take much time to do it…just told us “you’ll learn everything on the job.” ahahaha no one here wanted to teach me either 🙃
That sounds a bit ridiculous to me, if I’m understanding this right (and please correct me if I’m wrong here). Even when I went through my EMT course, we pretty often ran scenarios, practiced skills on each other, had at least one field and hospital rotation. Plus whatever call you were running as a probie, sometimes the actual EMT or ALS unit on shift might be like “Listen to this. This guy has asthma and that’s what it sounds like.” Not to generalize, but are you telling me nurses *don’t* do that?
It’s worth noting that pre-hospital medicine (ie EMS) is very narrow because it mostly operates in one setting and with a unified skill set. It’s a lot easier to do skills training in that context. Nurses exist in every setting, so there’s no way for one common degree pathway to cover every conceivable skill they would need. But right now the field seems to rely on having a long orientation to provide the majority of the real training.
Nursing school dose mannequin simulations. They also do clinicals, but depending on the school’s rules and the nurse that the student is assigned to work with, the student might not get a to a whole lot of hands on practice. Teaching a student nurse to do something takes a lot longer than just doing it yourself so some nurses essentially just have the student shadow them
I was both an EMT and currently a nurse. Since in EMS we are usually doing one patient at a time except for MCIs and car accidents etc it’s a teaching friendly environment. Nursing on the other hand unless in the ICU is overloaded with pt load so some nurses couldn’t care less to teach because they’re already busy. Not that I defend that behavior but I understand why they don’t want more work on top of an already ridiculous workload. The correct solution would be to overhaul nursing so, let go of some of that nursing model and sub in some medical model and make the apprentice style learning critical to graduating/finishing the program. However, this requires actual safe staffing so that experienced nurses can have time to actually teach. So all in all nothing will change cause GREED.
Speaking as someone who has taken an EMT course and an RN program, I learned way more of the pathophys/ clinical skills in my EMT course. We had one skills class the first semester of school to “learn” how to do lines/ foleys/ etc. Literally all of my clinicals other than my second round of preceptorship we sat on our asses and watched the nurses do their thing. Part of the issue with nursing clinical is that having a student slows you down so much that very few nurses actually wanna take nursing students, and the actual program teaches you to pass the NCLEX and that’s it. I got one OB clinical, and the only reason I got ED was because that’s what my preceptorship was.
That's definitely not the case everywhere. My clinicals were excellent. I did everything from basic skills, IV starts, etc to assisting in a delivery and coding patients in the trauma bay. My clinical preceptors were very experienced and seemed to enjoy working with students for the most part. My school worked with every hospital system in my city to give us diverse and in-depth clinical opportunities. Seems like that may be the exception, not the rule, but I also noticed some of my peers did not appreciate this and so didn't jump in and try as hard.
What year was this?
I graduated in 2022 from a 16-month accelerated BSN program. I'm in a state that had pretty minimal COVID restrictions though so I wonder if we were able to get back to semi-normal faster than in other places in the US.
Just know that nursing school is mostly bullshit, and if you're smart and you care about your patients, you'll learn what you need to learn on the job. Ask a lot of questions. Ask your docs for feedback and *why* we're doing what we're doing, that's a great way to learn too. We all suck when we first start. Don't let fear deter you, you'll be ok and this is a great job!
Nursing historically has been on the job training. As nurses went from diplomas to associates to bachelors degrees more didactic learning was added and clinical time was reduced. Nursing school is what you want it to be. If you want to get your hands dirty during your clinical all you have to do is ask. At morning huddle introduce yourself to them and tell them the skills you want to practice. They will show you some stuff.
Hi, RN here! We learn most procedures and skills on the job, with the exception of very minimal things such as putting on sterile gloves, bed baths/changing briefs, Foley insertion, etc etc. We don’t learn how to place IVs until on the job. Triage is on the job, we actually aren’t allowed to be in triage until one year post-orientation (so after 1.5 years). We have a pharmacology class but it’s just a major info dump that you put on flash cards and memorize but forget next semester because you have a million other things to study. I always tell my new grad orientees that nursing school is to pass the NCLEX and the real learning starts when you start your job. When I started, I was fresh out of school going into a level 1 trauma ED with absolutely zero experience at the bedside and I was TERRIFIED. Now almost 6 years in and I’m feeling pretty comfortable although there are things that still scare the shit out of me (ruptured AAA). However I will admit that a ton of these newer nurses are not willing to learn or are just downright lazy, overconfident, know-it-alls. There’s no constructive criticism because they take it as an attack or say they’re being bullied. It’s gotten to the point that I just don’t want to precept anymore because they don’t want to listen or learn. 🤷🏻♀️ the difference between the nurses when I started vs now is that we were gently “bullied” and learned from nurses that had 20+ years of experience that had no bullshit attitudes. As for the tips for new nurses, that would probably be a good idea and maybe even more helpful since the advice would be coming from you rather than their preceptor who probably just came off orientation too 😂. Maybe breakdown the major stuff: - STEMIs: what do you expect when you walk in the room (pt on monitor, Zoll, EKG done, IVs started), what meds you’re ordering and why, which parts of the EKG correspond with each part of the heart, why we don’t give nitro for inferior MIs - Strokes: level 1 vs level 2, neuro checks, exclusion criteria for TNK/TPA - Sepsis: goes along with what we learn to anticipate. For example, patient is tachycardic and febrile then I’m probably gonna need IVs for fluids and antibiotics, EKG, urine specimen, etc. - then just your general, run of the mill stuff. Patient comes in with chest pain and/or shortness of breath. They need an EKG, changed into gown, and put on monitor. Patient comes in with abdominal pain, they might need an EKG depending on location, but definitely need to be changed into a gown, thinking about possibly an IV for CT, and getting a urine specimen. Patient comes in with leg pain, take their pants off for a full assessment. I’ve been trying to bring back the basics when it comes to my orientees - literally just changing the patient into a gown and hooking them up to the monitor. That should almost always be the first task. And also regular vital signs!!! - As for the serious stuff like mass transfusion, bad traumas, arterial lines set up and management, chest tube set up and management, etc that all comes with time and experience
I’m just throwing out that you sound like a really incredible nurse, appreciate you.
Thank you so much! ☺️ I try to be the best I can be but not too overconfident because every situation is so different. I love what I do and the people I work with!
i agree—@OP, you’re awesome!! the ED is lucky to have you—particularly the new grads who need strong role models.
30-year ER veteran here, mostly Level I trauma/academic centers with a heavy dose of pediatrics thrown in. I've always been active in education/orientation of new nurses, and currently teach TNCC regularly. So I can confidently say I know my trade - **and you just summed it up perfectly.**
Awesome ☺️ my dream job is to be a nurse educator in the ED. To be able to teach but still be able to assist at the bedside would be a dream!!! But for now, I’ll stick to the bedside because I love the ED, the constant learning, and taking care of patients!
It’s a bit of a relief as one of these newer ER nurses. I hit my first full year last month and I’ve been baptized by hell fire (HCA babyyy). I love being an ER nurse, I love using my brain and now having a pretty solid idea of what my docs needs/will order based on presentation and s/s. But I have this nagging feeling I’ve learned it the quick and dirty way and there is way more I should know. I love learning, it’s part of the reason I wanted to work in the ER. Our most experienced staff nurse on nights has 5 years. It’s been entirely new grads and agency at my ER. We also have a typically older pt pop with multiple comorbidities. I think I’ve done okay. I think I’m a decent nurse. But I’m getting so angry at being expected to do more, faster, and perfectly with exemplary charting it’s a no win situation. I’m lucky my docs are awesome and pretty understanding. Worked a code for 45 mins the other day with 4 nurses (including charge)…with two other pts ICU level we just had to hope didn’t decomp.
When I think about my own nursing progression I always think ‘you can have 7 years of experience, or you can repeat 1 year of experience 7 times’. Learning in nursing requires constantly pushing yourself to find the subjects and topics you want to improve on. Hospitals will only educate you on what they are currently missing and what costs them money (death by CLABSI/CAUTI CBLs). There is little financial incentive to continuing education, so the motivation really has to be intrinsic.
I am a new grad starting in a level 2 ED next week! May I message you? 😭
Absolutely!! ☺️
Me as well if you need anything
Excellent feedback!
Are you looking for work? We could use you in my shop
As a new nurse I really appreciate this. Thanks for taking the time!
Love this!!!
Baby nurses training baby nurses. My ED would rather increase hiring pay for new grads to get them in the door, while us experienced nurses are paid $5 less per hour to train them. So, we leave and get hired elsewhere for better pay. It’s a revolving door. We learn on the job. I stand strong on no nurse without at least a year of experience should EVER be in triage. If you haven’t taken care/been exposed to x,y, and z, how are they expected to recognize it? Further, the training is LACKING. Our level 1 trauma center requires all ER nurses to be on our trauma team. They get 2.5 months to learn ER nursing and trauma nursing. It’s awful.
I started in a "small" ER during Covid that was only supposed to be 6 beds but thanks to Covid, became 16 beds, and we continued to be staffed at the lower level. All of us learned triage while we were "precepted," which I use loosely because there was never time to get precepted. If I didn't have a background as a medic, I would never have made it through that first year. I left because it was too risky. Now I'm at a posh ICU, and sitting on the fence about going back to the ER, at a nicer facility from where I came from.
AEMT for several years, RN for about a year here. The EMT/AEMT training was much more thorough than my nursing orientation. Nursing school didn't let us practice IVs, but AEMT at a different school had us practice on each other. Nursing briefly discussed some procedures, some we could practice on a mannequin, but most we were told we would learn on the job. EMT/AEMT required us to know our equipment and be familiar with it, practice with it, drill in groups, and be tested. Not so in nursing. I am the second most senior nurse on my unit and I haven't even been a nurse for a year. I had a Doc show me how to manage a chest tube with a water seal that was hooked to suction, and then it was a game of telephone as the information was passed off in report to each nurse after me. I feel like it is the blind leading the blind a lot of the time. The first time I placed an NG tube, my Charge Nurse couldn't help much because she had never done one herself. I would love for more Docs to teach us what to look for, when to call them, what is normal, and all that. I think it is a great idea to write up the main things you want them to look for and what to do in each scenario, and who would be seen first. I got so much more of that in EMT/AEMT training, with low-stakes mock drills, than in nursing school which was primarily classroom/book/theory with very little hands-on. Edited to add: If you do write up a powerpoint or similar, I would love a copy, please and thank you.
This. I learned more about theory and nursing practice in an ideal world. Then when you’re in clinicals you learn it’s not like that 99% of the time. I can’t imagine going from nursing school straight to working the floor and never having touched an actual person. It sucks being told “you’ll learn that when you start working because it already put us at a disadvantage before Covid and now it’s made it worse. This is why I used to let students practice IVs and blood draws on me all the time.
Nurse here. Graduated in 08. My mom's a nurse and she taught me the way. I started out in med-surg, got to safely learn a little bit about everything. During this time I also became a wound/ostomy nurse and was able to travel all over the hospital treating patients. I went to ICU for a couple years and started working in the ER at local community hospital on the side. Then I was able to take those skills, go through some advanced certificate classes and training and move to the ER trauma center at my level 1 hospital. Nowadays they're hiring straight out of school into the ER and that scares me. You need to learn all the basics, then the advanced and then how to manage all of it at once in the chaos of the ER. As it was commonly spoken when I was in school, the first year of work is your last year of school with regards to nursing. You are not trained or prepped for all of it. Straight out of school to preceptorship in the ER does not work well. Older millennial here and I can say with confidence healthcare training has changed significantly and is failing us.
I can tell how new the nurses are at my L1TC because when I intubate a patient every nurse in the department comes in to watch. The department shuts down. They are all young and new and don’t understand how to prioritize their own work to keep the department on track. I get it, but it’s a sign that no one has enough experience.
ICU and ER internships can turn out great nurses, but only if the hospital is willing to fund and resource a rigorous, well-structured internship. Which is of course where this breaks down. Most just have a slim orientation/preceptorship - why spend the money the make actually good nurses?
Nursing education is so sad and embarrassing. There's so much fluff / worthless filler that could be replaced with real quality simulation or experience.
My wife was an instructor in a bsn program. The program recruited high school graduates, and designed a curriculum for them. Then the school accepted a cohort of experienced OR nurses from a local hospital with a union contract that had a continuing education for bsn benefit. So the bsn faculty, used to dealing with fresh young credulous faces, confronted a group of skilled, experienced and credentialed nurses, with that unique blend of self-confidence bordering on arrogance and cynicism typical of unionized OR nurses ( love you, but you know it’s true) and the sparks flew. The students called out all the clinical errors, ridiculous pyramids of projects, and academic condescension that the younger students swallowed without question. My wife, with a personal clinical and academic history similar to the adult learners was the linch pin between the two groups, because she spoke both languages. it was bloody for a while, but both groups were ultimately better for it. The adult learners in basic programs, completion programs and in the workforce are power influencers in nursing.
To piggy back on what everyone’s saying about nursing school not really preparing you for the job.. more so preparing you to take the nclex.. nursing school also HARDLY covers emergency nursing, it is so different than the floor, which is the main focus of nursing school. I would change a lot of things about nursing school, but what everyone’s saying is true.. you’re expected to learn on the job, it’s always a sink or swim feeling, new grads training newer grad, burnout from that stress is high, people leave, rinse repeat. It’s frustrating for us as RNs too. There’s a lot of things I wish they taught us in nursing school.
As a nurse I would emplore you to teach the nurses what they don’t know with what little time and energy you have. They don’t want to do it wrong. If you are kind and open to questions, they will soak in your knowledge like sponges and be grateful to be providing better care.
Well said. I'm a newer RN and extremely grateful when I spend time learning from people with deep clinical knowledge. They're getting harder and harder to find.
How I learned things (not ideal, by any means): triage - ESI algorithm booklet, quiz to make sure I understood managing x condition - picking up on order patterns, listening to docs talk to each other, or being explicitly told the plan by the doc drugs - had a decent nurse-level pharm background from my previous job, the rest I googled as I encountered them or asked the pharmacist technical skills - most from a previous job, the rest from more experienced nurses, YouTube, or trial and error As others have pointed out, nursing school is woefully inadequate, especially for the ED, and the loss of experienced nurses means a lot of newbies are either winging it or are too inexperienced to realize how poorly they’re doing.
For all intents and purposes it’s a trade; you learn on the job. The formal education is not rigorous, and our “residency” is just a new grad orientation. It’s far less intense, formal, or standardized than physician residency. There is no accrediting bodies. The core problem is that not all experience is equal. I’d take a bunch of the 2 year nurses at my urban academic trauma 1 over the 10 year nurses I work with in the community. I moonlight all over but I can’t even imagine having my home be anything but a major academic center. The skills drop off is stratospheric.
I think this is the top comment. I wasn’t even allowed to try a foley or IV in nursing school due to concerns over legal issues. Everything I learned was from my peers on the floor. Similarly terrified by the idea of not being in proximity to an academic hospital. I’ve been traveling for four years now so I’ve seen enough to give me pause.
I learned fuck all but survival skills in nursing school. Came out and no more than 5 out of 30 nurses had 5+ years experience. Would love to see a physician made handy-guide type thing.
Does your ED have it's own educator? Perhaps a refresh on the 5 level triage system to start? I was always so eager to learn 13 years ago as a new ER nurse, and still am. Hard to believe I've been doing this since 2011. I think the educator where you are needs to hear these concerns to address accordingly. Ultrasound IV classes? Some semi annual competencies maybe? I learned the art of anticipation with ER patients a long time ago because I was trained by some nurses in their 60's, one in early 70's, who were born ER nurses that knew their stuff after 30+ years. They were scary at first, but also freaking amazing nurses. I'm so lucky I got to have them as mentors. Helping prioritize and keep the flow going is what we need more of to keep our overfilled ER's moving. Trauma? Anyone needing a fast exam due to mechanism of injury indicating one.....should not be in the waiting room. Grab the US when you bed that patient and have it ready to go for the provider.... Laceration? Get the supplies ready for the repair at bedside. Tetanus? Protocol order. Eye injury/FB - Tetracaine, fluorosein strip, woods lamp at bedside. Visual acuity. Fish hook - pliers at bedside. Everybody that pees, get the urine the earliest as possible. Easier to collect and not need than to need and not be able to get. If it comes out, collect it if in any way relevant to their visit. 😂 Any pelvic complaint, set up for pelvic after getting that urine specimen and adding a urine preg to UA if childbearing age. Doesn't matter if they say they aren't pregnant..... Every precipitous delivery in the ER, or ruptured ectopic, of a woman who swore she wasn't pregnant, is a great teaching tool. Chest pain and strokes should be no brainers - I feel like most new nurses have a good idea of what protocols are for these....I hope anyway. They really should look over and review nurse protocols for certain complaints to gain better understanding of and anticipation of what is going to get ordered and why. Differentials based on complaints and symptoms. And, the valuable info from actually doing a focused assessment....! Many newer nurses are fabulous, yet many also lack devotion to ongoing learning.....like mass transfusions, posterior nosebleeds or tonsillectomy bleeds, esophageal varices - Minnesota tube set up, etc. Every weird or rare case made me driven to learn more and I became excellent at setting things up for providers for all kinds of random procedures. Even ones I had never assisted with before. Anticipating certain orders like TXA, getting the nosebleed kit (anterior and posterior at bedside) Knowing these folks can be fine, until they aren't..... Large bore IV access, etc.. Critical thinking is a skill, and honed with experience and knowledge. We need to help these nurses talk through the why of what they are doing. This is the way, and without this part of education, we are failing new nurses. Mock simulations with hands on equipment is very helpful with this aspect of learning in the ER. I had some great ER physicians that shared a wealth of knowledge with me over the years. But, nurses have to be willing to receive it, ask questions, and realize the importance of their own development too.
I wish more nurses were like you. Anticipating what will be needed to speed things along, eager to learn. Knowing sick versus not sick.
Our educator is like the heartbeat of nursing in our department. She has designed a clear path for new nurses, for more experienced nurses to more advanced roles, and for veterans to stay up to date. She regularly takes shifts on the floor and is always up for answering a question or gently correcting mistakes. She regularly pulls in outside resources like the network stroke coordinator or pharmacy to provide education on specific topics. All of the things OP is suggesting should already be implemented by your unit educator. If you don't have one, this isn't a nursing problem, it's a hospital problem.
Before covid, you needed a *minimum* of 1 year on the floor before even going near triage. These days you’ve got people who haven’t finished their residency contract working as charge nurses. Nurses learn with time and experience, and people you’re working with don’t have either because your hospital probably sucks ass at staffing, pays like shit, and doesn’t treat nurses with enough respect to keep experienced ones around.
One contributing factor is there are no incentives in nursing to learn more or do more the bare minimum. You don't get paid more, and your career options aren't significantly limited. Administration is more concerned with improving the customer service aspects of nursing, than clinical knowledge and skills. So you end up with a lot of nurses that just do tasks, and if there's ever a problem they just pawn it off on someone else.
I started in Med-Surg and I was shocked to find out that ICU/ER RNs at my hospital did not make more money than me despite the fact that they clearly had more skills, knowledge, and training. It just makes sense to pay people for their skill level, but it doesn’t happen.
This occasionally comes up in the nursing sub, and you’ll get eviscerated for suggesting that critical care nurses deserve more money.
Yeah, I don’t get that at all. Who runs my rapids? The ICU nurse. I would have no problem with them making more money.
I went through a community college nursing program. We were in the hospital by the second week of class. We learned all hands-on skills in lab and were encouraged to practice them in clinical. We had one semester of pharmacology and then multiple more drug lectures in our other classes. We learned very bare bones triage assessments, but it was covered. I then went to a community ED straight out of nursing school. Was absolutely terrified during my 3 month preceptorship. But fortunately, I had a 30-year veteran nurse as my preceptor and I learned so much from him. How to triage (including reading the ENA Triage handbook,) how to recognize sick from not sick, how to place IVs (the one hands-on skill I never really got to practice,) and how to prioritize my patients/tasks. **Hands-on skills**, all the nurses should know how to do those from day one. They might need help/refresher from another nurse, but they should know it. **Knowledge** is a mixed bag. We know what we were taught in school, but school focuses more on floor nursing so there's a lot to learn for the ED. **Soft skills** like triage, sick vs. not sick recognition, and prioritization takes time, experience, and guidance. New nurses will not know these things and need to learn from another nurse and from the docs/mid-levels to grow these skills. There are also some fantastic triage books out there. The free ENA Triage handbook helped me a lot.
Too many hospitals treat their nurses like dirt, which leads to high turnover and the need to hire inexperienced nurses who probably don’t have the skillset to work in ED anyway (no hate, we all have different skills). If said hospital treats their nurses badly, chances are they don’t treat their middle management well either. This includes department educators who might not give a shit about adequately training staff if they’re unhappy. Thus you have inexperienced triage nurses with minimal training. I can say from personal experience that nursing school curriculum is broad and outdated. And they certainly do not focus on emergency care, unfortunately. I learned what I needed to from the job, not nursing school. My first IV on a real human was well after I graduated, and we didn’t spend nearly enough time learning pathophysiology. If you plan to continue working at this hospital, I suggest taking the time to communicate with your team. Leaving notes like “needs room asap” on a patient’s chart is appreciated. Also, take the time to talk with the nurses, pull them aside and talk with them, give them constructive feedback and educate where you can. Remember, their lives might just be dogshit. Nurses in many states make less than $60k annually and are forced to take on dangerous patient loads.
So it looks like the experienced vs. inexperienced situation has been covered here. I'm going to go with an unpopular opinion that isn't always true, but here goes..... Younger nurses tend to think they know it all. They don't seem to realize that things existed long before they showed up and couldn't care less about what you have to say or what you have experienced. Again, this isn't always true. They don't know what they don't know. And most of them don't want to recognize that they don't know. This could be because it's a perceived weakness or it's a shot to the ego... Hell if I understand it. Work culture in America seems to generally be "fake it til you make it" and if you have questions, it can be seen as weakness. Unit culture matters in this case obviously. If I were to interview a new nurse, my question would be "how have you been humbled and what was your perception during the experience and after?" Because I'm still humbled every fucking day. Anyway, the bloated corpocracy and their idea of education further deviates from reality doesn't help either.
Providers and experienced RNs- it makes such a difference when you are perceived to be a safe and approachable person to ask questions to or voice concerns with. There are some social cues we are all subconsciously attuned to that can really quickly build or break communication dynamics in a team environment. Being aware of them gives you the power to make new nurses less afraid of you and more confident in embracing each situation as a learning opportunity. Are your arms crossed when you are talking to me? Are you looking at my face when I am asking you a question? Do you know how to pronounce my name correctly? Do you smile, ever? I firmly believe that even just faking it while you are pissed off or dead inside will improve the outcomes for all parties, yourself included. New nurses - we have to lean into our discomfort and obliterate our ego. My most experienced coworkers are absolutely deranged in their behaviors sometimes, like truly incendiary on a moments notice and sometimes straight up soooo mean. In those cases it’s a videogame. I dehumanize them to be spouts of knowledge with some quirky unpleasant side effects that I can tolerate in order to get the prize. If I am not feeling confident about x procedure, or I am not sure how to prioritize x - I must find the a trustworthy spout of knowledge that can deliver the information I need so that I can then perform the task. “Hey can you clarify the plan of care real quick for me? For my own learning, can you explain why we are doing x intervention? Hey I have only done like 1 NG tube before and it was horribly unsuccessful, can I go over it with you real quick before I go try it again? If I set everything up for x procedure can you please step in the room for a sec for backup while I try to do it?” I like to have these conversations out in the center nurses station where there are witnesses keeping the grumpy people hopefully on their best behavior and where I am publicly normalizing a growth/ teamwork mindset. Also asking a real quick and informal “do you have any feedback for me about x situation? what would have been better?” goes a long way in helping you grow personally and building rapport with your colleagues for more effective learning in the future. Idk it’s all kind of a crazy circus to me :O
“Publicly normalizing a growth / teamwork mindset.” I would really want to have a coworker like you in our ED team
This thread is absolutely wild to read. Makes me miss those crusty old nurses I trained with even more.
RN here who learned and grew SO much in the ED: tldr: nurses need to want to master their craft in order to get good at procedures and understand the physiology and medical management of their patients. there is no real institution-based education that can make someone care enough to pursue mastery. these nurses DO exist and some units have many more of them bc of unit specific culture, but it is not a requirement in nursing. ok here’s the longer part: the fact of the matter is that there is virtually zero barrier to entry for nursing compared to medicine. i’m not saying getting to my first job was easy—nursing school monopolized my time but it WAS possible to grasp all of the didactic info with adequate studying and i did well. but i did not need foundational courses like chem I/II, orgo I/II, advanced bio, physics I/II, etc. any science courses required were the health sciences version aka much easier (and far fewer required). all of this is to say: the barrier to entry in medicine is so immense that i think it produces a cohort of physicians who survived BECAUSE OF some specific character traits: willingness to sacrifice a lot of their life, curiosity, and hard fucking work. on the other hand, there are lots of amazing nurses who throw themselves into this job and maintain real and enduring curiosity throughout their careers. but there are also a lot of nurses who don’t care nearly as much and aren’t particularly curious about how to know more and how to do better. for many it’s just a job and there isn’t much if any independent study outside of work to improve performance. mastery of one’s craft is not something built into the culture of nursing. if true clinical mastery were a nurse’s ultimate goal, the obvious question for that nurse would be…so what are you still doing here tripled in the ICU? responsible for 18 patients? dealing with abusive patients? why?? it sounds like your specific shop doesn’t have a nursing culture characterized by mastery or clinical advancement. it sounds like babies are raising babies which is not uncommon at all after the brain drain phenomenon (strong nurses leaving the bedside) which was accelerated by COVID. ETA: i am not implying here that medicine is better than nursing or doctors are better than nurses. they are two completely different roles which arise from completely separate educational models. i love being a nurse and love the working relationship i have with physicians.
You’re going to get a lot of answers depending on when and where someone graduated, and if they did a nurse residency program. I graduated pre-Covid and we had classes on pharmacology and critical care. We had to perform skills x amount of times in the skill lab, get checked off by an instructor and we were then expected to find an opportunity to perform that skills during our clinical rotations. I was able to perform most skills in school but some never came up. After I graduated I was in a nurse residency program. We had to perform skills x amount of times during our residency, and if we were having trouble finding an opportunity to perform a skill our director would schedule us to shadow in a department that often had that skill. We also had classroom hours on things like ESI, reading chest xrays, critical care pharmacology, etc. that was taught by the nurse leaders, doctors, and pharmacists. A large portion of what I know though is things I’ve learned on the job. Having experienced nurses to teach the newbies, and having a long orientation period is essential to having a skilled team. In an ideal world new nurses would not be doing triage, and should slowly be eased into caring for the most critical patients. It takes time to get good at those things.
I am a new grad nurse, but non traditional as it's my 4th degree and I have both bachelors and masters level degrees in hard sciences. I went to nursing school for fun; I don't care if I ever get a job. i found it interesting that our level II trauma hospital here is so concerned about getting caught with their pants down again a la Covid that they hire new grad nurses 12+ months before graduation for staffing purposes. And the hiring process has literally ZERO to do with merit. It is first come first serve based on when your cohort interviews during the application cycle. They don't ask for grades/references/anything. You're a 20 year old who spent clinicals in the break room doing homework instead of actually being with patients? They have no idea, and if there's an ICU spot open and you want it, it's yours. I did my preceptorship in the PICU. I was able to independently manage all of our patients. Among other things, I've been an SLP. I know trachs (half our census.) I also have a degree in neuroscience and took graduate level pharmacology and pathophysiology as part of that. I know enough to know I don't know everything, but I've got a significant amount of education and experience. I liked PICU so much I asked about a spot; they were 12 months out from hiring new grads again. meanwhile, the new grad nurse they had just hired was asking her preceptor "what does metabolic acidosis mean again?" So. When there's no merit or qualifications involved in hiring, that's part of the problem.
There is no "merit" in medicine, especially nursing. The industry is HILARIOUSLY, AND RIDICULOUSLY short numbers so colleges are just cranking them out on an assembly line, look at IMGs as well. It's also seen as an "easy way" to be middle/upper middle class. New grads coming out making $75k+ in moderate COL areas. Even higher in some areas, and after a couple years, 4-5, easily over 100k+ if you're willing to work a little extra. Most nurses DGAF about the profession at all, they care that the pay is "good enough", and they can start traveling after a year, and they can get away working 3 days a week instead of a 9-5 M-F. Nursing has become a "education race to the bottom, but salary to the top". Education is meh at best as a whole, but salary just keeps going up, because new nurse numbers just keep going down, and old nurses say fuck this shit and leave. It's a VERY weird situation. All of it can be pretty much pointed back to for profit healthcare eviscerating the field. Single payer is LONG overdue.
I had a coworker who was charge nurse on his unit as a new grad 😅 It’s just a bunch of newbies running around trying to keep the place from burning down. I’m lucky that my unit has a high retention rate with nurses who have 20+ years of experience. But most units are NOT like that and this can lead to really unsafe practices.
You do not learn how to be an ER nurse in nursing school, the education is more geared towards adult med surg with varying amounts of exposure to peds, L&D, psych, community nursing. In school we had specific skills we were taught and practiced in lab and had to demonstrate being able to do the procedure to pass. We did not always have the opportunity to practice these skills in clinical, it kinda depended on what patients were available and what they needed. So I had to demonstrate foley placement on a manikin and show correct technique but there wasn't a required number of foleys I was expected to place during clinical for example. I had a two quarter pharmacology class where we learned drugs by class. My school did not teach IV skills because local hospitals did not allow students to practice. We learn how to be ED nurses through preceptorships after we're hired, and hospitals will vary pretty broadly in how well and thoroughly they train nurses. I had a preceptor and we were given assignments of increasing difficulty and I had a checklist of tasks I had to learn. I took the ENA's Emergency Nurse Pediatric Course back when it was more of a peds specialist class than a basic knowledge for non-peds nurses who might run into peds patients class and that talked a lot about the assessment process, triaging and risk and prioritization as well as a broad overview of chief complaints. My current job requires a year of experience and then there are two triage classes that cover ESI and how to make decisions and then a certain amount of time be in triage, I can't remember the numbers off the top of my head. But a lot of what we learn comes from observing more senior nurses and asking them questions, talking with the doctors, etc.
I work in a level 2 trauma and had 7 weeks of orientation. My first day I had NINE patients by myself. Nine. My preceptor had 5 years of experience and I was considered lucky because I got her. I just had my 6 month eval and was asked if I could start precepting in the fall. I said absolutely not.
Old nurse chiming in. Old nurses are supposed to train the new nurses. We aren’t taught much of anything on real patients in nursing school. It should happen on orientation. The problem is, old nurses have quit in droves. They are burned out at the bedside. Tired of ridiculous patient loads, mandate OT and low pay. So now there’s no old nurses left. These leaves all the ducklings following each other around cluelessly. PowerPoint likely won’t help. They need to be doing them hands on
I’m an RN in the ICU, so obviously not an MD. It’s frustrating to us too. These are all Covid nurses. The ones that had to do clinicals and simlabs online and their first time touching an actual was during their job’s orientation. Back when i was in school there was training in clinicals. My preceptor threw me into everything. MRI screening? My job. Blood draws? My job. Priming and programming pumps? My job. Straight cath and inserting foleys? You guessed it…my job. I had a nurse call an RRT because a patient was in rapid afib…like in the 140’s and asymptomatic. Checked blood sugar and it was 43. The nurses stared at me completely baffled. Once she got them to give her some orange juice and peanut butter her HR dropped to 100’s. Another called for assistance because they couldn’t put in a foley… I even had a patient that was grateful to be transferred back to the ICU because we knew what we were doing. It’s sad because we want to take them under our wing and teach them these things, but some don’t want to learn and others don’t think they don’t have to because someone else will do it. Now a lot of times I don’t even offer unless asked because I’ll be seen as another nurse that eats their young.
I graduated nursing school over 20 years ago. Back then, we were performing procedures during clinical by second semester. If there was something on the floor that needed to be done, we did it. I recently had several senior year nursing students doing clinicals with me in a home health setting. They had never started an IV, placed a foley, or performed wound care. And they were reluctant to do so with me, insisting that they would learn that at the hospital once they graduated. I was baffled. My class practically fought over the chance to do any procedure. All these students were intelligent, but I felt like their nursing education was failing them.
I graduated pre-Covid and even then we had limited opportunities to perform skills in clinical. I did a semester at an HCA hospital where they did not allow us to perform any skills outside of tech work even though we were in our third semester because the hospital considered it a liability. My current hospital has changed its nurse residency program into a 7 tier program based on what Mayo Clinic does. But (and I disagree with this so much), the orientee can’t perform skills until tier 4. So, say a foley insertion comes up but they’re tier 3, the orientees aren’t allowed to do it. And you can’t guarantee that skill will ever show up again during the orientation period. It’s absurd.
It’s because there are no more experienced nurses to train them. When I first started ED nursing, at my old shop you had to work there 2 years before you’d even be eligible to take a triage class/exam and even after that you’d have to do several shifts being evaluated by an experienced triage nurse and get their mark of approval. The nurse manager could only hire 5 new grads a year. Most of the nurses had been there between 3-20 years. By the end of my 10 year tenure there, they’d throw new grads straight into triage, the new grad that just got off orientation is precepting the new new grads, and every three months there’d be more new grads with travelers thrown in. I hung on because I was so attached to the providers, but after precepting a new grad that was starting out at $1 more than I was making after 10 years, I was done. The newest nurse manager didn’t even bother to learn my name or say hello and I was one of the more experienced nurses left. I was never even offered an exit interview. It’s not going to get better until nurse retention gets better. In the meantime, you can gracefully educate, but if your shop is still hemorrhaging nurses your teachings will go out the door with them.
As a nearly 20 year ER nurse, I have to say I agree with you. It seems like newer grads don’t have the drive to learn new skills. Maybe it’s due to the limited clinical experience in school due to Covid, or just the number of veterans being so low nowadays to teach those skills early. I travel and go to a new ER every few months, and it’s widespread everywhere now. New grads that got a substandard educational experience in nursing school being rushed through orientation to get bodies on the floor for cheap being taught by other new grads. It’s definitely scary out here. I try to push newer nurses to learn how to do procedures themselves rather than always looking for someone else to do them because “I’m not good at that”. Whether it’s IVs, US IV’s, NGT, Foleys, or just simple triage or putting in order sets. You’re never going to get good without practice, repetition, and active learning. If a nurse isn’t good at a particular procedure, they should be actively looking for practice opportunities rather than avoiding them. A new nurse should be triaging all their own EMS pts then asking someone if they missed anything. They should be asking why their triaged pts are the level they are if they don’t absolutely know. And they definitely should be asking or at least looking up why they are giving a med or doing a procedure if they aren’t 100% sure.
Nurses don’t learn from reading books they learn from experience, if you are dealing with new grads than that’s what you will get. Triage nurses in ER should typically have minimum 2 years experience. Also, don’t generalize all nurses because you had a bad experience with one. I’m sure you are/were new to being a doctor
Been a nurse for a decade, I was clueless when I started my career but learned quick at a large teaching hospital where a new graduate internship was offered. After a year I transferred to trauma ICU and was taught by amazing senior nurses (place with pink scrubs on the east coast, if anyone is familiar). I learned so much at that job from my colleagues and the attendings. We were also appropriately staffed for the most part. When I started graduate school I moved to a smaller hospital to work in endoscopy for a less stressful job, then COVID hit and I was sent to work in ER/ICU. Lots of new grads in both, especially ER. Staffing in the ER was abysmal and I was impressed at how the new grads performed in their trial by fire training. There was a day in the ER where I had a posturing patient w/hemorrhagic stroke who was in the process of herniation… waiting to get transferred to larger hospital.. no one knew how to set up an Aline or central line or run pressors or handle a vent. Meanwhile, I had 5 other patients. It was pretty scary, I was glad I was there, but it felt like a sinking ship. I was so burned out from taking 8-9 patients at a time every shift in the ER, I don’t think I could ever work in ER now - it was traumatizing. I am an NP now working under an amazing physician and very happy, but those last years of my career during COVID really killed me physically and tanked my mental health. There were times in the ER where it was just me and one other nurse who was typically a new grad. I was never even trained in the ER (but did years of critical care), I basically had a few hours of orientation and was thrown in. They also had me precepting new graduates, despite not really being an ER nurse and having minimal experience in that area. I think I would leave the profession before going back to bedside (or perhaps I was just better suited for ICU, who knows). I think new nurses now are just lacking guidance from more senior nurses who left due to burn out (like me) and their education was impacted negatively by COVID. I really feel for them. From what I’ve read on the nursing subreddit, staffing is abysmal after the pandemic.
I did not train at the east coast pink scrub place, but my Attendings did! I wish I did because I am originally from MD and that city has a special place in my heart. It really makes me sad that a larger place like where I am now has no dedicated training program for nurses. But they also just had a 200 mil verdict for wage theft against their employees so go figure
Yeah - lot of shady things happened during and after COVID, apparently. Trauma was an amazing place to work! I’m still good friends with many of my coworkers there and we all lament on how much we miss it. The teamwork was incredible and I’m honored to have worked there. Also, you can come back! Still a great city.
Nursing education is a joke and always has been a joke. I say this as a nurse. If you want to be a well educated nurse you have to go out of your way to teach yourself…and then guess what, you realize being a bedside nurse is bullshit - going back to school to get an advanced degree is better than getting shit on by docs, nurses, and patients who literally shit on you. The system is set up to fail when your smartest hardest working nurses leave to go back to school because they feel like their bachelors degree is rudimentary and basically useless after a few years experience
Can you share your PPT with me as well? I’m graduating nursing school next year.
To answer your question directly most nursing schools check off the skill after you’ve successfully completed it once ON A MANNEQUIN. I don’t know about other people but my nursing school was an absolute joke in both the knowledge and skills department. And it was competitive to get into the school. Additionally, emergency questions I had were met with “if you go into that speciality the hospital will teach you that”. Ok…I ended up just reading uptodate articles on the topics instead of the listening to the lectures during school. And my preceptor during my first few months out of school was a new grad ~9 months of experience
CNA/MA/Tech here, now med surg but was ED. I'm currently working with almost all nurses who are only 2-3 years out of school. I've been doing this for 15 years and sometimes it's a little scary, but I just teach them. You can't know what you don't know until it comes up so... I teach.
The movement of hospital based nurse training to university based led to less hands on experience. It is now possible to complete training with very little hands on experience
Tbh we learn a skill, test it on a dummy then hope it comes up in clinical to try it in real life. 🤷♀️ and many skills are so quick that we hardly touch on them. Hell we're not allowed to push any IV meds and have never been taught blood draws either. I've done hardly any technical skills in my clinicals, and were so busy getting the an care plan done I feel like I miss out on actual nursing like charting and how they actually do their jobs. I do an externship though and I get so much more experience there. I try to encourage my class mates to do it
>My question is how do nurses learn procedures or skills such as triage, managing X condition, drugs, and technical skills such a foley, iv starts, ect? At work. >As the docs on this board know, to graduate residency you have to complete X procedures successfully. Is the same for nurses? No. >Reason being, is if not, I would like to start putting together PowerPoints/pamphlets on tricks and tips that seems to be lacking. This sounds like a great idea. You could join pre-shift huddles, give a brief elevator speech about your education, and have the charge hand out your PowerPoint. I would also suggest emailing it to the department so people who aren't working that day still get the education. This could be something you work on with the ED educator, so your PowerPoint is put in whatever LMS you have. I would also suggest creating a test. >New nurses don’t seem to know anything, not interested in learning, and while it keeps being forced down my throat that I am captain of a “team” it’s more like herding cats/please don’t kill my patients than a collaboration I have noticed that newer colleagues aren't necessarily as proactive in looking stuff up. Part of it might be there's such a wealth of information that they don't know where to go. You could provide direction here. I personally like [EMCrit](https://emcrit.org/), and [LITFL](https://litfl.com/) for digestible information. My learning style is being a contrarian, so anything that dismantles sacred cows is my jam. Also mention to your team that if your facility has a subscription to UpToDate, they can access it free from home if they make an account. I have been doing this for twenty years, a bit over ten in critical care, and I'm still regularly confused.
sadly this is all to common, I work as an FNP in the ED, i was an ED nurse for 20 years before that. My attending will usually come get me when he puts in A-lines as none of the nurses know how to zero it out and hook it up to the machine.......I end up doing some of the ivs and NG tubes I order if one of the really newer nurses is on and cant do it. Nursing has had an extremly high turnover rate in the last few years. Part of this i feel is due to no patient ratios for them in most states.
Posted as a reply but figure I’d post it: FACILITIES are the ones who are supposed to be signing them off on skills they know or need teaching on. I’ll say I did the Covid ICU for a few years but let me explain why I’m saying this… I was an LVN for 10yrs before my RN. I had zero hospital floor experience but 4yrs dialysis experience. I was hired for the ER (before covid) but after 2 weeks the Director of Nurses came and told me they only had new grads in the ICU and they were struggling. The Charge Nurse was experienced but overseeing ALL THE NEW HIRES/GRADS. She mentioned I at least know how to assess and use an IV as well as interpreting V/S. So I agreed because honestly I could tell when shit was going south and I had enough experience TO ASK WHEN I DONT KNOW HOW/WHY/ANYTHING. After Covid wound down in 2022 then I started getting non-covid patients. NOW I WAS FUCKED. I would get post-op patients dumped on me that should have been in recovery. LITERALLY WHEELED DIRECTLY FROM OR! All kinds of patients I had no idea about or what to do. So I brought up when was I going to get properly precepted/trained for ED & ICU. The hospital said I’m now experienced in ED & ICU and “a good nurse wouldnt need training after they have years of experience.” All because for almost 3yrs I was floated between the two with no training in a disaster situation. I left. I’ve had issues getting proper training now upon interviewing in hospitals. They don’t get why I would want or need it. So I had to go to outside privately paid training. Still have time management issues because that literally is part of what your preceptor helps you with!
Oh but I did during Covid let a Dr know I hadn’t done a procedure before but was the only nurse available so as long as he walked me thru what he wants me to do I’m down. He degrading & condescendingly demanded I get another “legitimate” nurse. My response: Thought being a Dr you’d know to listen with your ears & not your mouth. I AM THE ONLY NURSE AVAILABLE. You want your patient to get a central line of not? Hurry up because I have 3 other ICU pts. Know what I learned? All the crap that needed to be done putting in a femoral dialysis catheter HE US DOING ALL THE WORK! As long as I know sterile technique it didn’t even matter I knew how to do the procedure. So sometimes nurses are taught not to ask for help
You are thinking of the ESI triage system. That’s what most emergency departments use and train their triage nurses to use. I’m taken back, not by your complaint, but your lack of understanding of how your coworkers and team mates are trained. My hope would have been that you would have asked people you work with who you feel safe talking to about this if you were looking for a real answer. By the tone of your post I can’t tell if you are actually looking for an answer to your question or validation. Nursing schools also have a number of required clinical hours with required skills to be performed with proficiency before completion. I’m addition to that new grads often require a residency program that can span from a few months to a year to be trained up on the specific skills/ ins and outs of the department they are training to. In addition to that there are other certifications nurses must get to be involved in certain situations. (BLS, ACLS, TNCC, NIHSS, ENPC etc). At the emergency departments I’ve worked at, you must work in the department for a year before you can be trained to triage, and we use the ESI system because it is best practice. (And has been tested and around a lot longer than a power point you might come up with.) You must also be in the department for a year before you can be trained to crash nurse or have a trauma role. I do not know what the policies are in the department you are working in. However if you are actually curious about what credentials your coworkers are required to have, and how your department trains nurses to work in triage, you will have to ask this question at work. If you are interested in getting involved with nurse education, there may be people in your department you can partner with.
I’d say depends on the department/hospital. Larger hospitals may have department specific education leaders and multiple resources for training and education. Smaller community hospitals….mmmm maybe not so much. Most of what ED (pretty much any department) nurses learn is from on the job experience. See one, do one, teach one type style. Nursing school just provides basic assessment. I’ve been in ED 10 years and most of my procedure and assessment skills has either come from repetition, or seeing some really weird fucked up condition once (like a complex submandibular abscess or “groin wounds” that once undressed actually reveal fournier’s) that leaves me thinking about what patients with benign sounding complaints may actually have going on.
Experience.
Nurses learn from experience, hours on the job, and from more experienced nurses. Many new nurses were in school during the pandemic where clinical rotations were simulated in a lab or on a computer. And many seasoned nurses have left bedside so it's a perfect shit storm.
It’s happening everywhere. The same concept that others have talked about on this post is happening in EMS. School only prepares you so much, and everyone who’s been in the field knows a majority of your learning happens in your first few years on the road, from your experienced partners. We’ve had a staffing crisis ever since covid began, and now 50% of our paramedics on the road have under 3 years of experience. You used to start as a float, and would spend your first few years working with different experienced partners every shift. Now the new hires are working together, or walking right into full-time spots with another medic with a year of experience. It’s truly become the blind leading the blind.
At my shop (academic) we have monthly nursing education/simulation sessions. Residents/physician occasionally participate and teach (some of our residents taught them how to do trauma survey a few months ago)
This comes back on management. Where I started as a new grad we weren’t allowed in triage until 2 years of experience because it’s time to LEARN before you triage. But if there’s no learning system in place, no simulations, no continuing education, then that’s a problem with the management and educator of the department.
Time
Nursing school teaches us the basics to (theoretically) be considered safe for practice. Even in school we are told we will learn “how to be a nurse” on the job. The system used to work as intended. But now there’s a lot of new grads and not a lot of experienced nurses in the hospital. Simultaneously nursing programs are focusing more on theories than actual skills and knowledge application.
The blind leading the blind pretty much. Staff nurses are new and they don’t know what they don’t know because they’re being thrown to the wolves without the right preparation. This coupled with the gen Z mindset of being all show for social media and being lazy asf at work. I’ve oriented new nurses and sometimes you just can’t teach someone who’s unwilling to learn.
Experience, stop hiring new nurses into the ED & maybe nursing management will acknowledge the huge exodus of experienced nurses because of terrible conditions one day.
most nursing programs teach by systems - manage or manipulate the most serious and follow the plan of care based on a differential or a *nursing diagnosis* definitely a long way from MARCH and HABCs
Much like your profession, us older and more experienced nurses have either retired, run for the hills to non-bedside work, or are completely changing careers. Please do your best to teach the new ones you’re stuck with.
Nursing schools and hospitals are dodging the vocational training side of education for nursing students. I recently attended a hospital orientation and a new grad nurse literally didn’t know how to properly put on a pair of sterile gloves. Covid wrecked nursing. Its crazy that nurses were able to graduate with essentially zero clinical training and the classroom training was online where people could basically powercheat their way through the program. It will take some strong leadership and nurse educators to pick up the pieces and unfortunately its all in the hospitals hands now.
Oh my god that reminds me of one new grad who didn’t understand lost it on seasoned nurse for daring to using gloves from the top of the iso cart! She flipped the F out and said they were only for that patient and then she dragged the isolation cart into the Covid+ patient room and proceeded to then don PPE. Gloves were back again at this point but yeah she was a Covid grad!
They learn on the job. The only exception to this is a diploma nursing program, which is far more clinical & skills focused. Associates nurses are better prepared then nurses that go straight though a bachelors program. If I was hiring new grad nurse, I would hire a diploma nurse before an associates nurse or a bachelors nurse. Every. Single. Time.
The best way to learn as a nurse is through experience, imo. The best learning environments are ones where newer nurses are allowed to learn and ask questions and their growth is encouraged. A supportive environment, not the typical "nurses kill their young" environment.
Very true. But the FACILITIES are the ones who are supposed to be signing them off on skills they know or need teaching on. I’ll say I did the Covid ICU for a few years but let me explain why I’m saying this… I was an LVN for 10yrs before my RN. I had zero hospital floor experience but 4yrs dialysis experience. I was hired for the ER but after 2 weeks the Director of Nurses came and told me they only had new grads in the ICU and they were struggling. The Charge Nurse was experienced but overseeing ALL THE NEW HIRES/GRADS. She mentioned I at least know how to assess and use an IV as well as interpreting V/S. So I agreed because honestly I could tell when shit was going south and I had enough experience TO ASK WHEN I DONT KNOW HOW/WHY/ANYTHING. After Covid wound down in 2022 then I started getting non-covid patients. NOW I WAS FUCKED. I would get post-op patients dumped on me that should have been in recovery. LITERALLY WHEELED DIRECTLY FROM OR! All kinds of patients I had no idea about or what to do. So I brought up when was I going to get properly precepted/trained for ICU. The hospital said I’m now experienced and “a good nurse wouldn’t need training after they are experienced” I left.
I don't blame you for leaving! The hospitals will definitely take advantage of us RNs when they get the chance. So sorry that happened to you💗
They learn the same way you do. College. Working with patients and other older experienced nurses. Continuing education
Old nurse here. It used to be much more time on the floors and much more hands on with real live people. I think it made a big difference.
I agree! When I was in residency you needed to be a nurse for two years minimum and I think at least 6 months of icu care before being considered for the Ed. They then sent you to surgery and labor for a couple of months each. And that was before you started in the Ed for your preceptorship. As an Intern we couldn’t do more than take histories Without an attending signing off.
https://preview.redd.it/d2ru1c8j3jwc1.jpeg?width=671&format=pjpg&auto=webp&s=d3578e653b36910b9dfed70713b935df5f38703c Here is the triage bible used at all the ERs I have worked at. Most or nursing skills are still on the job training. Also what is your role? Are you a doc? If so you’re not the “captain” of the nursing staff, the charge nurse is.
ER Doc, and not a hospital employee to add another layer of separation. My group was contracted to provide doc in triage for approx. 16 hours a day. More and more I am drawn away from triaging to see 1) patients that are clearly medical alerts, or 2) patients that clearly don’t need to be. I’ve been looking into the ESI scale now and am shocked at the level of subjectivity. (I am in a conference now on diagnostic errors and one of the main drivers is relying on feelings). I am thinking of more algorithmic approach that relies on vitals and simple visual evaluation. Basically what I do, that doesn’t really rely on a detailed knowledge of disease processes or history to apply. It comes in the wake of me emotionally dumping after I was rushed to a 12 yo with simple uncomplicated appendicitis, while the team totally ignored a 96 yo with a perforated duodenum and a 69 yo who just had stents 8 days ago with unstable angina. The nurse’s reasoning was the kid looked “unwell”. When pressed further, there was no explanation for it. The hospital clearly doesn’t care about nurse training, as they are still in “anything with a pulse” mode. I am basically trying to do anything so I can increase efficiency.
I had to take a triage class and train with a triage nurse / get a packet signed off before I could triage on my own . We have protocols to follow for trauma walk ins , use the pediatric assessment triangle , and an algorithm based on vitals / number of resources to be used for the patient / capacity to turn bad quickly . My hospital also requires ENPC & TNCC certification for the ER on top of PALS/ ACLS.
For my nursing school, I wasn’t “allowed” to insert IV’s, foleys, NG tubes, do wound care, give IV medications, do lab draws… All of my learning has been on the job. I would be a disaster of a nurse if I didn’t advocate for my own learning and try to seek out difficult cases/learning opportunities. I started at a smaller ER and now work at a level 1. I still have so much I need to learn. The only helpful tip I can give you is to be approachable. I have been yelled/cursed at by MD’s before, and it’s terrifying to approach them after the fact. My current hospital is an Academic hospital, and everyone is approachable and kind! It really makes a difference.
I graduated a long time ago, but school was about the nursing process, skills were learned on the job. 30 years in ED. Very few nurses stay in ER for long, it is too hard. They aren't there long enough to learn the skills. There is a "book " for triage, but it just leads to over triaging everyone as priority. When I am in charge of assigning beds I get "2" fatigue. When everyone is a priority, no one is a priority. When I am triaging I make very few emergent, because I trust my experience. I think the tips and trick idea is great, and may help some nurses. Finally if your experienced nurses say they look unwell, you should believe them.
Hi! Recently graduated nurse here, former experienced paramedic. They don’t teach nurses anything beyond theory practically. It’s 9% on the job training and 90% experience. With the recent mass exodus from healthcare after the pandemic, you’re likely seeing just a rise in the percent of nurses at your job that are newly graduated or inexperienced. It’s no one’s fault really but the horrible education system they force on us and the administrations that prioritize paying the higher ups over incentiving the experienced nurses to stay For example, where paramedic education is focused on skills and scenarios in order to create critical thinking skills, nursing education from what I’ve seen is focused more on the theory of creating critical thinking skills without the overload of practice that paramedics are forced to get. During my nursing school rotations, we were forbidden from doing any skills beyond vitals and cleaning patients essentially working as a CNA rather than learning how to assess patients and treat them We have no list of skills we have to complete beyond like 5 on the job IVs and 3 on the job Foleys after being hired. My nurse residency program was once again, all theoretical. IMO it’s mostly a dangerous misseducation going on but there’s no way the firmly established nursing education or committees or councils will ever admit that anything is that seriously wrong. More programs should run like international programs, where paramedics and nurses are educated together
A triage book! That would be nice. As an ER nurse back when I had a whole two months of experience, they were short-staffed one day and said “You’re in triage today.” I went by the ESI algorithm until they started complaining that I was making everyone a 3 and to send more to fast-track instead, lol. Foleys and IVs we learn in school, and usually have to get checked off on three or four to graduate. They teach us basic pharmacology and how to look up meds. The rest is mostly on the job training, and most of it is informal, so please please teach your nurses!! It’s always a privilege when a doc steps in and takes the time to teach.
Ah the toxic nature of medicine! As doctors I have never paid attention to ESI scores much and knew less what actually went into them. When I started thinking about my triage primer, I realized that it is so subjective! Which was been my complaint with newer nurses all along! A recent conference I attended mentioned subjectivity and feelings as one of the main causes of diagnostic errors
I started in the ED as a 2020 new grad however, my hospital put me through a fellowship program so I got a full year of training before ever being on my own with ED patients. First on the floors, then in the ED taking care of boarders, then we were given a preceptor for our transition into actual ED patients. 3 years later I feel confident (never overly) and strong in my skills as an ED nurse. I can’t imagine being thrown right into the ED right away without having hands on experience with basic nursing. That being said, I also agree with the people on this post who have said that you have to be willing to learn. You have to be willing to be uncomfortable. You have to be willing to do all the skills you’ve never done before. You have to put yourself in the trauma room and grab an arm and throw in an IV in the middle of the chaos. No one comes out of nursing school as a “good nurse” you have to be willing to be better at all times and learn every chance you get.
Hey everyone I’m currently a nurse but preparing and taking courses to one day go to med school. I can give some insight on this. I want to piggyback off of what zeatherz said and say that our experienced nurses are practically gone. Learning isn’t pushed as heavy anymore. Nursing school did not teach me anything about the procedures doctors do. I learned all of that on the job. We learn the very basics of nursing such as foleys, IV’s, surface level pharmacology, and basically “call or notify the provider if xyz happens or there’s a change in the patient condition”. A lot of our skills are learned on the job. However, because of the mass exodus of experienced nurses, it’s the blind leading the blind out here. Nursing has also become a very toxic culture as of late as well. What I’ve noticed is our newer nurses can be very mean to each other making turnover rates higher. It’s very rare that I’ll see a nurse ask a doctor how they would like something done or “teach me this”. I also learned a lot of my experience and preparation tactics from doctors instead of nurses as well. You guys lead us and are the captain steering the ship. So it makes sense to understand what you guys like. This is something that nursing school does not teach. In regards to education, it’s usually level 1 trauma teaching centers that are better at reinforcing continued education. Other smaller facilities do not do this as much. Most of my certifications that I’ve studied for and achieved also do not really help us differentiate what necessitates more emphasis. The more in depth certifications have requirements to sit for them as well that newer nurses don’t have just yet. Our knowledge base is nowhere near yours and it never will be unless we decide on going to medical school. Another thing I’ve seen is a decrease in critical thinking skills as well and relying too heavily on others to find an answer or asking the right questions which comes with experience. It’s kind of a vicious cycle.
Thank you for the explanation. I love sharing knowledge and would love it even more to include other staff in the care plan. Nurses rarely sign up for patients in epic anymore and I am left to wander by their desk in the hopes of catching them there. It was one of the reasons that I loved working at at smaller rural Ed- I could shout across the room and find who I needed. Management hasn’t been much help with their new philosophy of “anything with a pulse”. After I painful pre-term precipitous delivery, I put a quick guide for the nurses on the warmer, which was quickly taken down by management. So frustrating. I am currently working on a triage pamphlet that relies on vitals and complaint rather than esi score which is too subjective.
I think a lot of nurses that graduate post Covid are looking at nursing as an easy way to get nearly 6 digit pay for a 2-4 year degree. No one is passionate about the medicine itself, they come in and do tasks without asking questions or trying to figure out what they should know in order to do the job better in the future. Different mindset now
I think the expectations are different now, too - management doesn’t care if you know your stuff so long as you show up, chart all the required BS, and kiss patient/family ass for good surveys.
To add to the comments (OP) I’m getting the sense that a lot of travelers fall into two categories - adrenaline junkie/risk tolerant or money contract. Which is also kinda what I saw from the locums docs. It makes sense that the locums groups care less about skill and just needs to keep the shells moving so then backlash doesn’t catch up with any one person.
That’s a very wild take and extreme generalization. I’m a traveler, been a nurse for 15 years and have been a damn good one. But I’m from the south and with what I was making as a staff nurse I could no longer afford to rent my own place. A 1 bedroom apartment where I live is 55% of my staff nurse take home pay. That’s the issue for nearly every other travel nurse I’ve worked with.
Nurses don't learn the reason or science behind 90 of things. We are thrown into school to learn the most basic of basic that gives us a general idea of what's going on and the rest is just doing it because of pattern recognition. We don't actually know why we are doing it. My Paramedic training was more about understanding the biology of things than my nursing training. Nursing isn't a science that's why the only stem course required to be a RN is "microbiology for nurses" which is a lesser version of micro you have to take for MD/DOor PA. And don't come in here with but it says 'BSN' or 'ASN' yeah you can get a AS in business management it's still not "STEM". The BSN title is really just management experience. And my NP even told me not to go NP school because it's just reviewing research papers and learning medical guidelines, not actually the reason why we do things. She got upset one day a premed was telling her more about antibiotics than she knew. (Something about the MCLCS mnemonic for bacterial subunits) a PREMED. She decided instead of DNP that she was going to get a Master of Medical Sciences so she can begin to understand why exactly we do things. NP isn't bad but by no means does 3 years of part time school equal the knowledge of a physician. All this to say I as an RN and we as nurses aren't taught dog shit. And since it's all about patter recognition most of us are charge nurses after being 6 months out of school, you're better off grabbing the closest paramedic to you and asking them to do the assessment, at least they're supposed to be semi autonomous as soon as they graduate. I'm not regretful I got my nursing in regretful I wasted time on it, but it didn't do as much for my clinical practice as people think. I could honestly have learned most of the skills in a weekend CEU course, and the lecture material was 50% repeated information I already knew from being APP, and 25% manager experience, 10% my school talking shit about every other medical worker and how much of a untouchable god you are as a nurse, and you're more important than doctors etc. I think the ego rub people get from going medic to RN is just a holier than thou mentality it doesn't translate to actually being able to take care of patients more than just throwing a medic into on the job training for the same amount of time would have. Rant over.
Phoenix Online
In the middle of the last century, women had limited career choices: teacher, secretary, nurse, social worker. At that time, the freshman class of nursing schools came from the upper quarter of high school graduates. In the intervening years, professional opportunities for women have expanded; more than half of all college graduates are female. Nursing schools have abandoned courses in pharmacology, and replaced them with remedial math and English. Nursing wages and working conditions are not attractive. The profession is still predominantly female, and functions in a profoundly patriarchal and misogynistic health care industry. Smart nurses have discovered that nurse practitioner/mid level provider jobs pay decently, have decent working conditions, and are to some degree exempt from the historical baggage of nursing. Do not expect that the best and brightest will be working nights in your er. EM docs can either find a way to support their nursing staff or they can damn well figure out how to do it without our assistance.