News Ticker

Nursings’s Dirty Little Secret

Nursing'sdirty little secret Nursing's dirty secret

New Nurse Krystal

It was a couple of years ago,  around three in the afternoon, another busy day on Tele. I dashed into the Supply Room to grab something and she was hunched in front of the supply cart,  hands covering her face, crying. Not crying as in silent tears sliding down her cheeks but sobbing with shuddering sobs.

“Krystal, what’s wrong?” She uncovered her face. It was splotchy and her eyes were swollen.

“I don’t know, I just..I don’t know I can’t keep up like everyone else” she started weeping again.

I put my arm around her.

“What’s going on? Tell me about your patients”

She was so distraught she could hardly form her words.

“One is getting blood but his IV infiltrated, I have to hang a heparin drip it’s my first time and there was the RRT and Jake (charge nurse) just gave me another admit from ED and the guy in 215A keeps getting out of bed I’m so afraid he’s going to fall”

“Is your RRT already in ICU?”

“The charge nurse <sob> is going to <sob> is going to get..”

“Going to what, Krystal? Send your unit of blood back?  Get a sitter?”

“Nooo…”

I interrupted her “Krystal. Have you had lunch?”

“NOooo….I’m just..I’m a failure at being a nurse I didn’t know it was going to be like this..”

“Krystal. Krystal. It’s not you. It’s not you. What’s happening is something they don’t tell you in nursing school.”

I hesitated, but then blurted it out

It’s Nursing’s Dirty Little Secret

Nursing'sdirty little secret

Nursing’s dirty secret

note: During this discourse, several nurses ran in and out, grabbing supplies and throwing Krystal a glance, some of which were fleetingly sympathetic. Some were not. One briefly patted her hand, but had to run as her own patient was not stable.

I went out to hunt down the Charge Nurse and found him sitting at the nurses station, seemingly oblivious. To his credit, he himself had less than two years nursing experience. Chances are he too, felt helpless and had no idea how to manage the situation, and so was avoiding it.


Krystal was two months out of orientation and judged herself a failure. She felt like she had made the biggest mistake of her life by choosing nursing. Her dream had turned into a nightmare.

How many other new nurses feel isolated in their struggle and drive to work with that sickening feeling of dread at the pit of their stomach?

Not Prepared

New nurses are not prepared to care for a team of high acuity, complex patients with multiple co-morbidities. It’s no wonder they feel overwhelmed.

It’s widely agreed in the literature that nurses do not achieve initial competency until their second to third year.

But a six month old nurse is given the same patient load as a six year old nurse. It’s not uncommon for a brand new nurse to find him or herself working nights in ICU, surrounded by….other new nurses.

Connect the Dots

New nurses cannot yet connect the dots, but there is an expectation that they should.

In the taxonomy of learning new nurses are at the knowledge and understanding phase. Having knowledge is different from applying knowledge.

When nurses graduate, they are optimistically brimming over with book knowledge. But patients haven’t read the book and don’t follow algorhythms.

Pattern recognition, which is a construct of critical thinking, takes time, takes experience,  and takes more than six months.

I’ll never forget being at the nurses’ station when I happened to look up into a pt’s room straight across the hall. He had “The Look”.  At that same moment, his nurse walked by, glanced in, and kept on walking without a pause. I bolted, yelling for someone to get the crash cart.

She had not yet learned to recognize “The Look”.

Task Oriented

Within nursing, calling another nurse “task-oriented” is a criticism. It means focusing on a task to the exclusion of seeing the big picture. This may be a fair criticism for an experienced nurse but not for a new nurse. It’s natural for nurses to be task oriented when they are first learning. It’s how we learn.

An earnest new nurse, intently focused on passing her 0900 meds and anxious because it’s now 0945, answers her phone. It’s Lab calling with a report of a potassium of 5.0.  She says “I can’t take this now. I’m passing meds.” Dutifully she passes her meds, including potassium, to the patient. She calls Lab back. “What was it you wanted to tell me?”

She was too absorbed to receive or discern the importance of new incoming information.

Nursing's Dirty Little Secret

Too much, too soon

When you are learning, the task at hand takes all of your concentration. A new nurse can’t be expected to multi- task while attempting to master the initial task. The notion of multi-tasking itself is currently debunked and is being replaced by the more descriptive term of cognitive stacking.

Yes, student nurses pass meds on patients during clinical rotations. But typically on two patients, not five, and while sheltered from the constant bombardment that staff nurses experience. And without an incessantly ringing phone in their pocket.

Nuances not Noticed

A new nurse may not yet recognize subtle changes in condition that can signal an impending deterioration in condition. A slight increase in heart rate in a post-op patient? It’s a red flag to an experienced nurse who is attune to early signs of sepsis, but isn’t even on the radar for a new nurse who is unquestioningly going to see that same patient as stable.

Read my article “The Spider Bite” about a patient who died in such a circumstance.

Sift Through the Chaff

Krystal’s post-op open heart patient is having runs of non-sustained Mobitz type I heart block, but his blood pressure is fine.

Krystal doesn’t yet know that post-op open heart patients experience transient and benign runs of heart blocks. She  spends an inordinate amount of precious time calling the doctor.

First she has to ask other nurses if she should call the surgeon or the hospitalist or the cardiologist. Then she forgets to have the am lab results on hand when she reaches the doctor.

In the meantime, another of her patients with CHF had bilateral rales this morning. While able to assess and recognize rales, Krystal does not immediately look back to the previous shift to see if this is new or look at the twenty-four hour I&O to determine his fluid status. His IV is going at 100 mL/hr. At 0900 an RRT is called because he is in flash pulmonary edema.

The experienced nurse will have briefly but thoroughly assessed the patient with the rhythm block, keeping an eye on the situation. She/he would have already obtained and administered Lasix to the CHF patient, saline locked the IV, and moved on.

Problem Solving

The IV on one of Krystal’s patients keeps alarming “downstream occlusion”. Krystal repeatedly goes in the room, looks at the line, the site, and pushes the alarm override. Finally another nurse comes in, flips back the covers and unfolds a kink in the line. Voila. Problem solved.

Later Krystal starts an IV on another patient. Pleased to have gotten flashback, she tapes it in place but realizes she pulled secondary IV tubing instead of primary. She makes a trip down the hall to the supply room. She returns and finally and deliberately gets the IV set up and running.

After a short time, it starts alarming and she keeps running in to check it. After multiple alarms and inspections, she realizes the site is swelling slightly. She discontinues the IV, goes to the supply room, and starts all over.

The experienced nurse knows when she first performed the stick that the site was no good, even with an initial weak flashback. She feels the almost imperceptible coolness of the tissue around the site when she runs a few drops in, and recognizes that something is just not right. She discontinues it and starts another IV right then, having brought in extra supplies.

Is it any wonder Krystal is so far behind?

No Other Industry

What if you got on board your transatlantic flight to France and the pilot announced “Welcome aboard! This is my first flight because someone called in sick and so they sent me over here. Usually I fly simulation helicopter flights but today I’m flying this big boy. Never flown one before but I’ve read the book. You know what they say… sink or swim, right? Oh wait, bad choice of words.”

Nurses are Complicit

Sadly, nurses are complicit in this culture.

Nursing's Little Secret

Nursing’s Little Secret

Nurses themselves have made missing meals and bathroom breaks a badge of honor to compete for who has the worst assignment or works the hardest or is the most self-sacrificing.

Missing meals is not a badge of honor, it’s a violation of labor law. Nurses clock out for meals they don’t take and clock out again at end of shift while staying over to chart.

Often nurses don’t question the unrealistic expectations. If they’re drowning, it must be because they’re not good enough. They just have to run faster and work harder. They want to be seen as capable of handling it all by their watchful coworkers. They want to please their manager by doing it all, without complaint, without missing anything, and without overtime.

Nurse scorn other nurses who can’t keep up. They roll their eyes and dismiss them with the phrase “He/she just can’t cut it.” This phrase is sometimes used as the sole performance feedback by preceptors and even managers.

“You’re just not cutting it here in ICU. Maybe you should try Med Surg.”

Patient Acuity and Decreased Length of Stay

Increased patient acuity and decreased hospital stays contribute to staffing challenges.

A nurse assigned to five private rooms does not have 5 patients. As a result of rapid discharges and admits, she/he can have cared for six to eight or even more patients in one shift.

As an example of higher acuity, hospitals are required to identify their own “critical values” and  have a process in place to deal with them. Several years ago, the glucometer machines at my hospital were set with the critical high level at 300. A few years ago, the critical high was upped to 500. Patients with a glucose of 500 used to be treated in the ICU. Now they are on Med Surg.

Nurses understand and emphasize that staffing issues are an ongoing concern that affects patient safety and nurse performance. Adequate nurse-to-patient ratios and safe patient outcomes are strongly linked.

An adequate nurse-to-patient-ratio must take into consideration the capacity and experience of the nurse as well as the acuity of the patient

Patient Safety and Nurse Safety Both Link to Staffing

It is proven that safe staffing ratios reduce untoward patient events. Safe staffing ratios:

  • Reduce errors
  • Decrease patient complications
  • Decrease mortality
  • Improve patient satisfaction
  • Reduce nurse fatigue and burnout
  • Improve  retention and job satisfaction

The Astronomical Cost of Turnover

Are hospitals stepping over a dollar to pick up a dime? Could hospitals save money in the not-so-long run by retaining and investing in their nurses to help prevent costly HAIs, falls, and other untoward events?

According to the American Federation of State, County, and Municipal Employees, (AFSCME) “if a 400-nurse hospital with a 20 percent turnover rate is replacing 80 nurses per year, the direct costs might average $800,000 per year, but the true total costs are closer to $4 million.”

Hidden costs incurred by hospitals include use of agency nurses, sign-on bonuses, re-location costs, decreased productivity, and lower quality of care.

 3M Littmann Classic II S.E. Stethoscope, Raspberry Tube, 28 inch, 2210 Paramedic Utility Bandage Shears Neon Pink 7.25 Inch Disposable Pupil Gauge Penlight

 Progressive Responsibility for Better Patient Care

Rather than a one size fits all orientation, consider giving new nurses progressive clinical responsibility over their first year.

To make it financially feasible, new nurses could be hired at a lower rate which would increase as they gradually and safely become more productive. New nurses who cannot get jobs will jump at the chance of being employed and being supported.

Nursing's Little Secret

Nurses need time to connect the dots

Health care leaders have an opportunity to collaborate and develop solutions that will build a safer environment for patients and registered nurses. Leadership support and recognition are key to assuring an appropriate number and skill mix of registered nurses who deliver safe quality patient care.

I would welcome your thoughts on this topic. Is this nursing’s dirty little secret? Or is this the acceptable status quo?

Should we ask the Mean Girls?

Read I Support Nursing Ratios

Related Posts

How to say No to an Assignment

Transition from Student to Staff

First Day Off Orientation

10 Rookie Mistakes 

 

Until next time friend,

Nurse Beth

Come visit me at Ask Nurse Beth career column at allnurses.com for all kinds of  entertaining and informative career questions and answers, and to submit your own question :) Or visit me at bsntomsn.org and StaffGarden where I also blog. Buzzzzzz…I’m a busy little bee !

AFSCME. The Cost of Failure. Retrieved June 2015 http://www.afscme.org/news/publications/health-care/solving-the-nursing-shortage/the-cost-of-failure

Benner, P. D. (2000). From novice to expert: Excellence and power in clinical nursing practice, commemorative edition. Upper Saddle River: Prentice Hall.

Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research, 24(4), 244-255.

Garside, J. R., & Nhemachena, J. Z. (2013). A concept analysis of competence and its transition in nursing. Nurse education today, 33(5), 541-545.

 

About Beth Hawkes (133 Articles)
Nice to meet you! I'm a Nursing Professional Development Specialist in acute care, a writer, speaker and career columnist.
  • April Kendall Donaldson

    LOL! I’m just now reading these comments. This year I’ll “celebrate” 20 years of being “part of the problem”. Some things never change. Zima and Eric, I hope we never have the misfortune of meeting each other. You’re both pathetic.

  • Samantha Stewart

    this article could be titled “reasons I left ICU”.

  • Jessie Rumans

    I am a nurse of 3 years with only 2 years of floor experience and this article was very much like how I felt when I first started as a baby nurse. I felt like I was a horrible nurse because I couldn’t keep up with my 5-7 pts depending on the night and available staff. I work a very busy floor that constantly has trouble staying fully staffed, even only 7-9 months into being on my floor there were nights I was the nurse with the most experience on a floor with 48 pts beds. And often still there are nights that, I am the one with the most experience and we have so many brand new baby nurses, which is nerve racking too. I still feel like a newbie often but way more confident than back then.

    Bottom line, I love being a nurse more now than I did initially for most of the reasons explained in the article above. I worked with some veterans that seriously nurture the newbies and some that nights made it fell like I was a meal every time I worked with them. I don’t plan to ever forget how it felt at first and know that the future of nursing is dependent on new nurses to keep coming or our staffing crisis will never improve in the long haul. Nurturing baby nurses and helping them develop whenever possible is so crucial AND finding ways to keep experienced staff around too.

    • Beth Hawkes

      I’m so glad you nurture our baby nurses. Be an encourager and feel good about helping someone else, right? I also remember some nerve-wrackng night shifts on my own that I wouldn’t wish on anyone. Thanks for sharing.

    • I love your story because it’s my story, too. We need more nurses just like you.

  • Pingback: Is There Really a Nursing Shortage? - nursecode.com()

  • songofdeb1

    Thank you! Great article and sadly contains many truths.

  • Debbie Bishop

    It’s only going to get worse. Firing all the older, more experienced nurses to hire greener, cheaper ones is going to start killing patients over the almighty dollar. There are no leaders anymore, just the blind leading the blind. Short staffing, lack of support and abuse gave me an early forced retirement, 3 heart attacks, open heart surgery, and loss of my livelihood. If I had to do it over again, I would have chosen the interpreter assignment with the Air Force, seen a good part if the world, and my work would have meant something. Screw nursing

  • Pingback: The Real Story behind Nursing Ratios - nursecode.com()

  • StCindy

    I think you missed something important in your suggestion to start new nurses at a lower rate of pay. Many of these newcomers are carrying school loan debt that makes such a plan impossible. You have absolutely put your finger on the new nurse crisis, however. When only new nurses are on staff, who do they go to for help?

    • Beth Hawkes

      I think new nurses are not 100% productive for a year..and shouldn’t be expected to carry the same load without supervision. Honestly a year in the hospital should be considered their lst year of school, or residency.

  • Daisy

    A couple of points:

    1. On my unit, the ‘old vet’ RNs are scarce, and highly valued. I could not have survived this first year without their guidance. Maybe my unit is the anomaly, but the older/experienced RNs do not eat their young, at least on my shift. I think they know they’d be handling triple the patient load if they did. They nurture us newbies.

    2. My unit has lost something to the tune of 34%-40% of its staff in the past 10 months, mainly due to chronic short-staffing, heavy ‘mandatory’ overtime with no end in sight, and major RN burnout. Because of that, inexperienced RNs ( < year under their belt) are being asked to take on charge RN duties at 6 months of experience and to precept brand new grads before they've hit 18 months of experience.

    3. We're working wildly over the safe staffing limit – sometimes coming close to 150%-200% of what is safe. I started with a cohort of new RNs, and 60% of them left before they reached a full year of employment.

    4. A progressive workload is probably the ideal, but with chronic short-staffing, it's not likely to happen. Hospitals do not seem genuinely invested in robust training or in retaining the nurses they do train. It's a like a mill – churn 'em out, let 'em quit, bring in the next batch of warm bodies. On my unit, they actually train you by giving you unsafe ratios your last few weeks of orientation, so that you can 'get used to the reality' – a reality that gives the lie to the BS they tell you in your interview, where they paint a rosy picture of reasonable ratios and supportive orientations.

    5. I will be leaving that unit before the end of the year. I promised myself I would stick it out for at least a year, and I have. Nothing has improved, and much as worsened. I will become part of that huge percentage of new RNs who ditch their first job within the first 2 years. But to do otherwise would be to become even more burnt out, possibly dangerously so, and certainly the statistical likelihood that it will eventually imperil my license is something I take seriously.

  • April Kendall Donaldson

    This is interesting. Can you fathom what the outcome would be, if you refused an assignment? The squeeky wheel gets the grease. Which of your coworkers would you choose to give your difficult assignment to? That’s what happens. Those of us, who don’t complain, have to pick up the slack. Whether the assignments are “manageable” or not, those patients still need care. There is no magical nurse factory pumping out nurses.
    My advice would be to ask for help. Do what you are able and ask for help. We’re all in this awful boat together.

    • Daisy

      We have people on my unit who routinely refuse assignments. Every assignment is a battle, and because they’ve been there a long time and/or because they are not afraid to be loud and pushy, they get what they want. Especially when you have a 22 year old RN who’s been a nurse for a hot minute who’s been shoved into a charge RN role and doesn’t know how to manage the personalities. Management rarely steps in on this. It’s sink or swim. And they wonder why the new nurses leave in droves.

      • Oh my goodness. Sounds like a total lack of management.

    • I agree we have to ask for help and many nurses do not.

  • karenclarkbond

    I completely agree. I am a nursing instructor and a PRN emergency department nurse. I already see the judgement of the students by the nursing staff. At least they figure out where they DON’T want to work when they graduate. We seriously can’t keep up with the demand because new nurses are leaving the profession faster than we can train them. I felt this way when I was a new nurse and had the scorn of the charge nurse who gossiped behind my back and laughed when I was frustrated. I made it through pretty much on my own because I was not one of the clique of the mean girls you spoke of.
    I also agree that we are wasting too much on hiring replacement when we could retain by treating our staff better.

    • April Kendall Donaldson

      While ridiculing new nurses is horrible, can you have some empathy for the old vets? Perhaps, instead of pointing the finger at administration, staffing, acuity, new nurses could respect their elders. I, for one, have never eaten my young. I was “raised” by old nurses who did. I realize now why they treated me like a rookie. I WAS a rookie. The charge nurse had a double assignment when I was a baby nurse, because I had no clue how to prioritize. She had to double check me, because if she hadn’t people could DIE. Maybe we need to teach new nurses to admire and mimic old nurses. This old hen might get grumpy, but she just wants her patients cared for properly. She also has an aching back and feet.

      • I’m not seeing an appreciation for the seasoned nurses, either. They have a wealth of experience and wisdom.

        • Eric

          Wow! You both just completely missed the entire point of her article. If that is the atitude you have then you are definitely part of the problem. She was not criticizing experienced nurses, she was discussing how to help new nurses become experienced safely. Or more to the point how we are not doing that well. If they are trained and educated better. Taught by “old vets” to recognise the things she discusses and more, then your “old vet” work load will improve as they learn and are supported. That would snowball over time when they began to support the next round of new graduate nurses. This would also reduce attrition and people leaving nursing entirelyentirely. This would improve things for everyone. Instead you just selfishly say what about me? Work load and burnout in “old vets” is another article and an important one. That said, if we help the newest of us, over time we help all of us. You both must be in hospital management, cause your attitude is what they have. As she mentions, “stepping over the dollar to save the dime” or in your case “why do we need to help the new nurses? What about us old vets?”

      • Zima

        You probably have eaten your young without realizing it, You are definitely part of the problem and no matter whatever explanation given, you may not change, I pray that whoever you will “raise” will find help!

    • It must be pretty awful being a clinical instructor and watching fellow nurses behave badly towards your students. I agree we would save more in the long run by being concerned about staff.

  • Pingback: 10 Responses When Your Preceptor Is A Bully - nursecode.com()

  • Pingback: Top Nurse Blog Posts 2015 - nursecode.com()

  • TMG75

    This describes exactly how i feel as a new grad. I have only been off orientation for one month, and am seriously thinking about quitting nursing altogether. I cry on my way to work and on my way home. I work on a Tele floor and I absolutey loathe it. This makes me feel not so quite alone with how I feel.

  • Wim Rawe

    hard to argue with any of that.

  • Pingback: Nurses: Trusted Strangers - nursecode()

  • Pingback: If Nurses Were Waitresses - nursecode()

  • Pingback: You May be a Nurse Part II - nursecode()

  • Pingback: You Know You're a Nurse Part I - nursecode()

  • Pingback: When you receive a warning at work - nursecode()

  • Pingback: 8 Things to Say When Your Patient Dies - nursecode()

  • Pingback: How to Write a Resume When You Have No Experience - nursecode()

  • Pingback: Med Surg Nurse - nursecode()

  • Pingback: Is there a Queen Bee on Your Nursing Unit? - nursecode()

  • Lenore

    Thank you for your article I really feel like there is a huge gap between school and practice. I am an adn graduate. I understand a bsn is what is pushed these days, but clinical experience, is what I need for sure before I take that leap!
    My first working experience was a nightmare. I was hired at a ltc/sub-acute facility at a reduced rate for training ($10) for 6 weeks, so I thought I would receive good training at least, come to find out after my 1st week I was asked to work as a nurse, at the same reduced rate, saying I could ask for help from another nurse who also had 25-30paitients or from the charge nurse if I could find her ( she had been overheard saying something along the lines of if they are an rn they should be able to handle it….needless to say it was overwhelming.

    • Lenore

      …I recognized it was unsafe and eventually found another job with better training and support, however I fear it will be or is the same in other places.

  • Pingback: Cell Phone - nursecode()

  • Today is my last day of my accelerated BSN equivalent nursing school after an early medical retirement from police work. I just finished my preceptorship training in the ER & hope to get a new grad spot at one of the local respected trauma hospitals. — That’s my goal although I expect med/serg and I truly appreciate this article from someone having already walked in the shoes.

    I caught myself a few time in the ER, when my preceptor stood back and let me do everything, beginning to think “I got this.” As I said before, I had a previous high stress job. But then I banged my head on the wall and realized my nurse wasn’t just sitting back chillin while I had it all handled. He was asking this nurse to check on me and that nurse to encourage me. He was also doing charting on my patient I was not allowed to do as a student and truthfully, would have had trouble completing as I had one STEMI Pt in bed 3, Blood hanging in 4, Psy Pt in 5 and a pediatric Pt in 6. I WAS OVERWHELMED! He was barely holding me above water. It was great. A little struggle grew me so much.

    It was nurses, like many on here, who got me through my shifts. And THANK YOU! Helping me turn a Pt so I can document a Stage 2 PU instead of searching for a CNA’s help, made me feel like you care. You also used that moment to teach me an “old school” trick that this new grad eats up and will use in my practice.

    If I can say one thing, and you probably know it, we are freaking scared! But that doesn’t mean we don’t want to learn. I may know the answer who are asking me but I’m on overload And I can’t synthesize that rails means I need to give Lasix. <–Hey I know what that drug does (I'm going to pass NCLEX).

    In the end, I love to see the many nurses here wanting to be and do better. I can't wait to work with you.

    (MSN -2017)

  • Pingback: How to be a Traveler - nursecode()

  • JMT

    Brilliant article! I’ve experienced this right out of school on a med-surg floor and again when I transitioned to the OR at another facility. The OR has been unlike anything I was trained for in school. This reality makes it hard me to recommend nursing as a career to others.

    • Beth Hawkes

      I know, and it’s sad. I do recommend nursing bc for me, the positive has outweighed the negative, but some changes have to be made.

  • Pingback: First day off of Orientation! - nursecode()

  • Pingback: Refusing a patient assignment()

  • Pingback: The Spider Bite and the Art of Nursing - nursecode()

  • Pingback: Nursing Pecking Order - nursecode()

  • Pingback: Traits and Characteristics of an ED Nurse - nursecode()

  • Anonymous

    As a nurse with over thirty years experience I was laid off due to age pay level and being grandfathered in to a pension plan. I was not the only one. They make you think you are a terrible nurse. In reality they jus c want to hire new grads and get you off the payroll.
    I fear for these young nurses with no experience.
    I worked with them on the unit and without back up I dont know how they can function in todays high acuity environment. Scary . Even the experienced nurses become overwhelmed but they have become better at prioritizing and advocating for themselves and their patients. It was the opposite when I graduated. It was hard th get a job. They wanted experience. Not anymore. Patients suffer because of the bottom line.

    • Beth Hawkes

      I agree with everything you said. It really says that experience is not valued

  • bethboynton80539889

    This is such a great post and dialogue, Beth. I can totally remember feeling like Krystal. Throw in an instance of disruptive behavior and it is the perfect set up for despair, anxiety, and failure. Sometimes I wonder if us seasoned nurses get some kind of twisted validation from seeing newer nurses struggle. Especially in organizations where the overall complexity of our work is not understood or supported. The feeling that finally, someone understands what it is like. I’m not advocating for it just trying to understand. Perhaps this could be integrated into solutions, i.e. find other ways to validate. Maybe a walk-a-mile-in-my shoes day w/ different leaders and nurses followed by a report out of learnings. And really, not having enough staff, especially chronically suggests a lack of understanding about the complexity of our work, an expectation for martyrdom, or a perception that money will be saved by looking the other way.

    The story you portray of the IV start from a seasoned versus new perspective is a brilliant example of how invisible expertise saves a lot of time and if we ensure this nurse has the time and skill to transfer her/his knowledge, we’ll all be safer and care more cost-effective in the long run.

    I worry about seasoned nurses leaving the field w/o transferring their knowledge etc. We may not fully grasp this until our hospitals have lost them….I don’t even like to think about it! Is anyone creating programs to access these nurses as they leave the workforce. Maybe your suggestion of progressive clinical responsibility for the newer nurse could be joined with a coaching mentorship process from bedside nurses retiring. (Before they are burned out). Maybe we could enhance the passing of the torch!

    Anyways, thanks for getting this issue out in the world.

    • Beth Hawkes

      Love your suggestions, esp the coaching. I see more of a medical model some day, with an emphasis on clinical. Thanks, Beth

  • Anonymous

    Great article. I became a nurse as a second career after leaving a very high paying job in corporate America. At nursing school is when I first experienced the “dirty little secret”. In addition to my corporate job I had previously had close to a decade of service functioning as an infantry medic. At nursing school I was literally told I needed to forget all that because now I would learn how to do things the correct way. What I found at nursing school was this continual feeling of being disrespected and marginalized because I had never been a nurse. I found this treatment proved how my instructors lacked any knowledge of anything outside of nursing.

    This attitude persisted at my first job after nursing school, as I was told some ridiculous phrase “nurses eat their young”. Now that I’ve been a nurse for more than a decade, and in medicine longer than 20 years I still don’t understand where this idiocy originates. I truly believe it most likely stems from having a leadership that hasn’t had any exposure outside of nursing, and believes that nursing is the only occupation where challenges exists.

    As a leader I’ve tried to combat this “dirty little secret” by hiring competent professionals that I actually treat with dignity and respect. I ensure they know how to do their jobs, but don’t penalize them for learning their roles. If this “dirty little secret” persists we’ll soon be facing a shortage that we created.

    • Beth Hawkes

      So well put, and I’ve wondered myself about the point you made “leadership (without outside) exposure” We’re slow to adopt best leadership practices from business.
      It’s kind of a combination of being insulated and…well, ignorant. Thanks for your feedback.

  • This is exactly what I tell my nursing students that following me for a shift. I give them the “real” nursing scoop and not just the nursing school strict rigid rules and I just don’t focus on looking up what the medications are and used for eat. In reality where I work the pharmacy does all that and we use a scanning system to verify right pt, right med, right dose, route, etc. more important is, is this something the other has taken before it is duppose to be taking? What will happen when they take it, for example lasix. I tell them how we do a real assessment.

    Then I find my Manager, also an instructor, doesn’t put students with me. Maybe this is why!? Maybe because I tell the student it is normal to feel completely overwhelmed and scared for the first one to two years. It is normal to pray all the way to work. It is normal to think you may have chosen the wrong field to work in. But the fact is it’s not normal at all! It’s just reality. I had a manager that had no idea I was a new grad and I would do what any reasonable human being would do when in crisis mode, I’d reach out for help and he would criticize me and later punish me with fact findings where I was labeled hostile or defensive. Well a year or two of standing up for myself and my patients led to ” witch Hunting” at my job again myself and literately caused me to have a nervous breakdown resulting in a leave of absence and a visit to Psyche. I was made to feel like I was the problem when actually my assistant manager had no business mentoring or managing a new grad. You are right a new nurse does not yet have critical thinking skills and they need support from their fellow nursing staff. Not all staff will do so unfortunately. Something needs to be done to help people succeed and to keep patients safe!

    • Beth Hawkes

      What a terrible and unnecessary experience! I’m so sorry. Just like new nurses are expected to perform like experienced nurses, new managers often don’t have the necessary skills either.

  • Anonymous

    I think some hospitals might be catching on to this. I did not go into a new grad program and started my career as an ED nurse. Having spent very little time in the ED as a student, I asked many questions about how I would be trained and what the training would consist of. They told me it would be individualed to my unique set of skills and knowledge (or lack there of in a lot of cases) and did not put a set amount of time that they expected me to be finished by. After accepting the offer and a few months in, I can say they really good true to what they said. In a way, it is kind of an “old school” type approach. I work on my preceptor’s schedule and she takes things slow and methodical even when chaos erupts all around us. Everyone on the team helps and when there is an opportunity to increase a skill I am not very profient with, the team gives me a chance to try. I guess what makes it so different is the lack of just “throwing me to the wolves.” To be honest, I learned more the first month in the hospital than in my entire nursing program. Even in the most stressful unit in our hospital, I never feel like there is too much to handle. My preceptor or someone else from the team is always there to give me the little (or big) boost to keep me caught up. Am I learning to stand on my own? Yes… But on a pace that truly is individualized. No one has ever said or illuded to the thought that I can not cut it. They know it’s an area I feel passionate about and that it will take a long time to get me fully trained. Ten guesses as to how large their turnover rate is… It’s very low. When the entire team is passionate about getting you to be your very best of really makes learning much easier. It also builds great working relationships where no one is afraid to ask for help or offer it. To the hospitals who expect a new grad to come in with minimal training and a lack of teamwork, shame on you. We need time… We need a caring atmosphere that encourages teamwork and communication… And above all, we need individualized training that caters to both our strengths and weaknesses.

    Thanks for another great post
    Matthew

    • Beth Hawkes

      I love your story. This is how it should be! So glad you are getting this great, supportive experience 🙂

    • Decie

      I wish someone would have shared this with me when I was a new nurse 3 1/2 years ago at the age of 51!!!! I can’t even count how many times I came home sobbing and saying I just can’t do this, I can’t keep up!!! Now I try to tell every new nurse to expect this, that’s it’s ten times harder than you ever imagined, BUT you can do it, you will survive!! We unfortunately set new nurses up for failure and burn out!!! I agree, something needs to change!!

      • Beth Hawkes

        It’s your experience and others that should never happen. Glad you survived and are helping the newbies

  • Anonymous

    This reads like my story, ten years on from walking out of ICU after only six weeks I haven’t shaken the feeling of being a failure.

    • Beth Hawkes

      Awful experience, I’m so sorry. It’s exactly why a change is needed.

  • JA-RN

    I’m a dinosaur, a 3-year diploma grad, now retired. Much as we complained at the time, we staffed the floors as students. We learned to give meds to 50 patients on some days & had regular assignments on others. We worked year-round, including weekends & holidays. Sure, we were way behind in the beginning, but we learned to multi-task & prioritize & developed necessary skills & experience. New grads coming out today need an internship as well as a preceptor. They don’t have the patient experience in their education to develop judgement & the skills that we learned as students. Our patients were just as sick as they are today & we didn’t have art. lines, Swan lines, etc. to assist with assessments. I feel sorry for the new ones. The schools keep churning them out, with the hallowed degrees, but nursing care has fallen by the wayside & is no longer valued by the bean-counters.

    • Beth Hawkes

      It has changed so much You need that patient experience, I think nursing schools are going to have to add it back in. Either that or extend the internships

  • Anonymous

    Most definitely nursing’s dirty little secret! I’m a new grad starting in ICU and I know I have a long journey to feel competent in my field!

  • Anonymous

    Just graduated in December & started my first RN job in January. Sadly, I find every word of this article true.

    • Beth Hawkes

      I know. And i just hate seeing new nurses put in this situation with these expectattions

  • Preach it sister!! Very well stated! Definitely nursing’s dirty little secret and it starting to be exposed! Great job (as usual)!!

    • Beth Hawkes

      Thanks, Joan Good to hear the validation

%d bloggers like this: