Too Many New Nurses in Hospitals
Too many new nurses in hospitals is becoming the norm.
Ashley was working night shift on Step Down Unit on a holiday eve, and looked around during huddle. She was surrounded by other new nurses. Ashley herself had graduated only 9 months before and been on her own for 5 months. The charge nurse, Yvonne, had been a nurse for just over two years.
That night Ashley was assigned six patients, one of them a post-op patient with a slightly elevated heart rate at 112 and a sub normal temp. Neither of these alarmed Ashley, who had never seen a septic patient and did not recognize the early warning signs. A sub normal temp and a heart rate of 112 were not as concerning to her as passing her meds on time and documenting.
Later on in the early morning hours, after an emergency rapid response was called on Ashley’s post-op patient, Yvonne, the charge nurse, said “Why didn’t you call me for help with her?” Ashley had no answer. She didn’t know she needed help.
On the other end of the hall, new nurse Kim’s post angioplasty patient needed to have his femoral sheath pulled. Kim was terrified as she had only pulled one sheath before, and that was under supervision, but tonight she was on her own. She prayed nothing would go wrong and had Yvonne stay with her, but neither she nor Yvonne were prepared when the patient had a vagal response and the heart rate dropped to 45. It took Yvonne and Ashley too long to respond and stabilize the patient, who had to return to Cath Lab. Neither nurse had the experience to safely manage a vagal response.
According to Del Bueno (2005), 50% of novice nurses do not recognize nuances of change even when they are signs of life-threatening conditions.
New nurse Chris walked past a patient’s room and glanced in while walking by. The patient was asleep and still, and Chris kept walking. Seconds later, the house supervisor, Barbara, also walked by and glanced in, but unlike Chris, ran in the room, shook the patient and called a code. What did Barbara see that Chris didn’t? A subtle change of color? A slackness of the facial muscles? A stillness? Barbara herself may not be able to articulate what alarmed her and it’s certainly not something you can teach- it’s experience. Expert nurses have cue and pattern recognition, zeroing in on problems instantly.
New nurses carefully hone their IV insertion skills. They focus on med pass and tasks. By definition, novice nurses follow the rules, do not tolerate ambivalence, and require supportive cues. This is not a criticism- it’s a necessary part of their development.
But it doesn’t change the fact that a high ratio of new nurses to senior nurses combined with high acuity patients leads to poor outcomes.
Too Many New Nurses in Hospitals: A Nurse is a Nurse
Nobody expects a new grad nurse to think like an experienced nurse or perform like an experienced nurse. Or do they? Patient care assignments on a MedSurg unit are often block assignments based on 5 or 6 consecutive rooms, and not on nurse competency matching patients’ needs. The assumption is that experienced nurses and new nurses are interchangeable.
The author recently heard of a new nurse having to float on day 3 of being on her own. A nurse is a nurse. Inexperienced nurses are put in high risk situations and frequently don’t get the support they need.
Too Many New Nurses in Hospitals: Burnout and Turnover
Much as most experienced nurses want to help new nurses, too many new nurses is a drain on existing staff. Experienced nurses burn out from serial precepting only to watch the nurse they precepted and poured themselves into a year ago leave the unit. The shelf life of a bedside clinical nurse is now so short that units are run by novice and advanced beginner nurses.
Experienced nurses move on to other roles, or quit nursing altogether. They leave due to pay, burnout, ineffective leadership, and stress. At some hospitals an intense focus on recruitment to the exclusion of retainment has resulted in compression of wages. At these facilities, new nurses enjoy high entry level wages while wages are stagnant for older employees.
Experienced nurses may not feel valued…because they are too often not valued.
Too Many New Nurses in Hospitals: Loss of Experience
The real cost to of losing experienced nurses is the loss of deep, collective group knowledge, both clinical and organizational knowledge. An experienced nurse knows how to unjam the printer, has the cell phone number of every hospitalist, and quickly tells patients to straighten their arm when the IV is beeping.
She can cajole Dietary into bringing up a late tray, and knows to call the MD early in the shift for a sleeping pill, anticipating the need, rather than waiting until 0100. Heart rate of 45 during a sheath pull? She immediately gives Atropine, restoring the heart rate to 85, problem solved.
Too Many New Nurses in Hospitals: Lack of Transition to Practice Requirements
There’s a reason medical school graduates do not practice medicine independently right after graduation. They are given time and allowed to grow while being supervised. Nursing does not have a standardized transition to practice pathway. Transition to practice training is entirely limited to what the employer offers. Some facilities provide very short orientations; facilities with residencies may offer orientation with a preceptor anywhere from 8 weeks to 16 weeks.
According to Patricia Benner, nurse theorist, competency is a level achieved at 2-3 years.
Novice nurses and advanced beginners describe nurses who have not yet achieved the level of competent.
Maybe it’s time to question the assumption that nurses are prepared to practice independently only weeks after graduation. New nurses deserve the chance to develop their skills without putting their licenses at risk. Patients deserve experienced clinicians.
Nurse Beth, Author “Your Last Nursing Class: How to Land Your First Nursing Job..and your next!”
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
Del Bueno D. A crisis in critical thinking. Nurs Educ Perspect. 2005;26:278-282.