As the new fall semester starts for thousands of nursing students around the world, many are concerned or anxious about their upcoming clinical rotations. The question is often asked by our student listeners, “How can I make the most of this year’s clinical rotations when I don’t like the specialties covered this semester?”

First of all, no one is expected to enjoy every aspect of the varied career options that comprise the field of nursing. The issue is not that you will enjoy every aspect but that you learn from the experience. Part of what you learn may be that you don’t want to work in pediatrics or psych.

Here are 8 tips to make sure you get the most out of the rotation, ANY ROTATION!

Be willing to work: Come prepared to spend your time working. Despite the time you think you are spending, no nursing student gets enough time in a clinical setting before graduation. That means you must make the most of the time you have. Be prepared when you hit the floor. If offered the opportunity, look over your patient charts beforehand and plan your day.

Keep an open mind: I’ve heard more than one nursing student make a statement like, “I thought I was going to hate this rotation, but now I think I want to be a long term care nurse and work in a nursing home.” I’m serious. A closed mind will be unable to learn anything. Work to remove your preconceived notions and focus on what is going to be positive about each rotation. Take 5 minutes and make a list of the pros if you have to.

Remember the golden rule: You are there to learn, but that doesn’t mean that you can’t be a helping hand to the unit. A little good will goes a long way. If you see someone who needs help with something, lend a hand! This shows a couple of things. First, you have demonstrated that you aren’t afraid of hard work. If you decide you like the working environment, you have put yourself in a position to be hired. Second, what goes around comes around. When you help someone, they will remember to help you. When a nurse has some interesting skill, procedure, or wound come up, they will be open to inviting you to come take a look. Help someone change some sheets and increase your opportunities to learn.

Divide and conquer: Team work with you fellow students is vital to success in nursing school. Working together in study groups, watching out for last minute scheduling changes, and sharing clinical experiences are all tried and true methods for nursing school success. In the clinical setting, you will need your classmates to proofread your nursing notes, patient care reports, and patient goals and interventions. They will also offer you additional learning opportunities by “sharing” their patients and

List your clinical needs: Knowing what you need to learn will help focus your efforts. Make a list of the clinical learning opportunities that you need, either for competencies or for you own satisfaction. If you need more practice placing a foley catheter, add it to your list. If you want to focus on wound care or replacing dressings, add it to the list. Review the list every week and make changes, marking off those items you’ve completed and adding others as they occur to you.

Use the Instructor: Share you successes and failures with your instructor. They are there to help you succeed. Tell them the areas in which you need improvement. They’ll watch the clinical opportunities for the class and be able to steer you towards the opportunities that will help you reach your goals. Also, ask the instructor to tell you where they think you need to improve. Sometimes, even though you have made a list, you miss something, a blind spot in your clinical education. Your instructor can help you identify these blind spots and help you move forward.

Have resources handy: Students need two things every clinical day. First they need a top quality drug guide. I recommend subscribing to an electronic drug guide like the one provided by Lexi-Comp for nurses. They can be updated regularly (much more often than books) and a good one provides all of the information a nurse needs, all carried in a PDA or on a smart phone. The second item needed is a clinical procedure review guide. You will probably already have one that is part of your textbook package. This gives you a resource to look over when you get a patient needing an intervention you haven’t performed before or haven’t performed often. With these two items, you will be ready for anything.

Know your staff: This goes hand in hand with the “golden rule” tip above. Get to know your staff. Not just the nurses but the techs, CNAs, pharmacists, and unit clerks. Nothing happens in a vacuum. A well run nursing unit is a team effort. Learn people’s names, say hi, and be respectful and friendly. This will pay off when you need something for your patient and can’t find the supplies, need an item from the computer, or just need an extra pair of hands to do something.

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A proposed Massachusetts law on minimum safe nurse staffing levels is working through the legislature there, but regional hospitals there are not just standing by and letting the measure pass without a fight. A $70,000 radio campaign has been launched to get the public to stop the compromise committee in its tracks.

This is in response to a radio and TV ad campaign run by the Massachusetts Nurses Association in June, supporting the measure. The Massachusetts State legislature will adjourn for the summer this week and supporters of the bill are hoping to push through a compromise between the house and senate versions of the bill before the recess.

Read the whole article here.

Predictably, the hospitals are saying the bill will increase the cost of health care across the board while the nursing union is citing serious patient safety issues involved in unsafe staffing. This is not an issue that is easily resolved since requiring minimum nurse staffing is not the same as actually putting it into practice.

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Check out our interview episode with Zenei Cortez of the California Nurses Association on their nurse staffing law.

Right Click to download (Macs Option Click)

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A Complex Problem

Nurse staffing is a complex issue. Hiring and retaining nurses in today’s competitive job marketplace is difficult. Some hospitals are working on methods to hire and retain more nurses and are having some success in the process, but what if they now had to go out and hire 10, 20, or 30 more nurses to fill voids in the schedule created by mandatory staffing levels.

The other side of the staffing issue is where are all of the nurses going to come from? Seriously, if every other story in the news is about plugging hole in the nurse staffing dike, how can you hire more nurses if you don’t have any more nurses to hire? They’ve got to come from somewhere and every statistic I can find says that the schools cannot keep up with the losses from retirement and death in the current nursing staff pool.

So, nurse staffing laws - are they a good idea or a bad idea?

The issue is complex, but if adequate staffing levels are available in the region, then I say that, yes nurse staffing laws can help. We have all seen what happens when businesses are left to police themselves without government oversight of some kind. Relaxed or removed regulation collapsed the savings and loan industry in the 1980’s. De-regulation and lack of effective government auditing created the Enron scandle. The current sub-prime mortgage crisis is another example.

When nurses are overburdened with extra patients, mistakes start to happen. Patient care is ultimately more expensive due to the costly errors that accompany the most common medical errors. Nurse staffing laws are intended to ensure that nurses have the time to provide competent care for their patients, in a safe and non-stressful way.

Just because our industry is health care does not make us immune to greed or the bottom line administrators who will opt to take a chance on patient safety in order to delete one staff position from a department or departments. The for-profit health companies (hospitals and insurers) need some oversight to maintain safe patient staffing.

In a perfect world, each patient would get their own nurse and physician to hold their hand through the illness and recovery process. But we live in a world that is far from perfect. In a time where energy costs are rising and hospitals and businesses everywhere are struggling to maintain a budgetary balance, too often the employees take the hit.

Nurse staffing in the hospital units should not be one of the jobs affected.

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Read the Nursing Show blog article, posted earlier this week, on what one hospital is doing to cope with staffing issues.

This week, I’ll focus on a couple of articles that deal with nurse staffing issues, both hospital based solutions and legislative solutions. Today, let’s look at one Wichita, Kansas hospital has instituted several interesting programs to retain and attract nurses.

Read the whole article here.

The program in this hospital is based on offering the nurses new opportunities to specialize in different treatment and care areas.  An example cited is the creation of an IV team.  Nurses who do nothing but start and monitor IV lines in the facility, as well as start specialized IV access points like PICC lines.  By having a specialized team for this task, nurses are freed up to take care of other patient needs.

The hospital also added to the “hospitality team,” techs and other non-nursing staff that assist with patient care by performing non-nursing duties.  In some areas, the hospital also implemented the use of remote monitoring of patients from a central location.  These programs gave nurses time to perform their dedicated nursing duties without getting bogged down with tasks that can be handled by unlicensed staff.

Finally, the administration addressed the causes of nurse turnover including job dissatisfaction, wages, and work environment.  Money was found in the budget to add to weekend and overtime compensation.  Nurses were included more actively in planning of hospital policies and programs.  Opportunities for education were added for career change or advancement.

The best part of this hospital’s commitment to improving nurse staffing on a long term basis was their response to area nursing schools that requested more clinical time for their students.  Arrangements were made to include more evening and weekend hours, as well as improving support for the student’s education in the various areas of the hospital by encouraging staff involvement in their rotations.

The bottom line effect of these programs is clear to the administrators of the hospital.  Turnover of nurses has dropped from 20% to 17%, meaning less time spent precepting new nurses, and less money spent on advertising for and hiring new nurses.  The net effects need to be fully examined in each facility but this article can go a long way to countering administrators’ claims of feasibility or effectiveness.  One hospital has proved them wrong.

Nursing is considered one of the top 5 recession proof careers. Home care nursing may not be as economically viable based on the price of gas and this article on the number of miles driven by the average home care nurse over the course of a year.

According to a report from the National Association for Home Care and Hospice, recent cuts and freezes in Medicare and Medicaid reimbursement rates have caused many home health agencies to cut back on necessary home visits and decrease the reach of their services.  This is especially hard hitting in rural areas where homebound patients depend on the services provided by these nurses.

Some patients have been told they are no longer in a home care agency’s range due to these cut backs.  Medicare used to offer a rural access fee to allow home health agencies and ambulance services additional funds to cover the increased mileage traveled.  That rural fee allowance was removed even as fuel prices continued to rise.

This problem underlines the basic issues that are tearing apart the U.S. health care system.  The patients most in need of primary care and home based services are the ones who are told they no longer have coverage.  These patients have no recourse but to access emergency services to arrange hospital transport to the ER, taking up valuable resources that might be needed for true emergencies.

When these patients have access to affordable and nearby health care, they do not have to abuse an overtaxed EMS and 911 system.  The answer is put forth in the article over at Medical News Today.

1. Recognize home telehealth interactions as bona fide Medicare home health services; if home care nurses can do more monitoring of patients over the Internet, it will cut back in the number of miles they need to travel each week to visit patients and save those visits for critical care situations rather than routine monitoring
2. Require the Secretary of Health and Human Services to revise the method for calculating annual market-based inflation updates and establish a temporary fuel cost add-on to 5
3. Commit to preserve the annual inflation updates for home health and hospice as provided under the Medicare law
4. Reinstate the 5 percent rural add-on for home health services delivered to patients residing in rural areas

Seems like a collection of good ideas to me.  Let’s see what we can do about getting these programs amended to make some sense.

With the death toll from air ambulance crashes nearing record numbers (16 so far in 2008, 2 short of the record of 18), I have to wonder when the FAA or other agency is going to wake up and realize that these services operate under a questionable emergency mandate.

These helicopters and fixed wing aircraft fly out to pick up patients who are in critical condition in an effort to bring them to definitive care. However, they often fly in questionable weather conditions when other commercial services stay grounded. The argument is made that it is an emergency situation.

What happened to safety first?

The truth of the matter is that these services are profit makers for their health systems, bringing in many more dollars than the transport fees charged to the patients. In fact, when you add up the critical care, advanced surgical interventions, and recovery and rehab fees these patients are worth hundreds of thousands of dollars apiece!

I have talked to some local flight nurses and paramedics about how the safety processes work. It is often left up to the crews to determine if they think it’s safe enough to fly in questionable weather. A single dissenting vote and the helicopter stays on the ground. In the face of $100,000+ in lost income, though, I wonder if there isn’t some amount of pressure from above when a crew repeatedly opts for their own safety instead of taking a questionable transport call.

The fact of the matter is, when you compare commercial safety records to public service based med-evac helicopters like the Maryland State Police units, there is a broad divide. The MSP helicopters have hard and fast rules for safe flying conditions. They don’t break them, period. If they are grounded then the transport falls to the ground ambulances.

The same rules should apply to the commercial services. There should be no “gray area” where employees, under pressure from their bosses, are expected to make decisions about their own lives and the lives of their co-workers. We don’t need to lose more valuable flight nurses, paramedics, or pilots because of the greed and glory seeking practices of a few physicians and administrators waiting safe and sound in the hospital for their well-insured patient to arrive.

It’s about saving lives (our own included), and not the money!

In part two of the series on advice for new nursing graduates, I continue with the interview responses of recent nursing school graduates from the last few years. (read part one here)

The question asked of them was:

“What were the biggest surprises or challenges when you started working as a new nurse?”

1. Dealing with Senior Nurses — It’s often hard to come to a new work place as a recent graduate in any field. Nursing students are not immune to this. Students arrive with new ideas and practices and this can cause a prickly reaction from the nurses on the floor. Some have become settled in their ways but in most cases old ideas don’t equal out of date ideas, any more than new ideas make them “better.” Show some respect for those who have gone before and try to learn from them instead of telling them about your new and improved methods. If you have learned a different method or technique, communicate with your preceptor, mentor, or supervisor and follow their lead.
2. Afraid of Saying “I Don’t Know” — It is hard to tell someone you don’t know how to do something when you think it is something you should know how to do. New nurses come in to the work environment with a variety of experiences behind them — even those from the same schools. One student gets a chance to use a variety of catheter techniques while another had no clinical opportunities, one student is the NG tube queen while another hasn’t done it since first year, and so on. Be confident in the skills you know and don’t be afraid to ask for help.
3. Using Critical Thinking — The instructors in nursing school talked about critical thinking all of the time but it isn’t until a new nurse has a patient on her own that she understands how much she needs to use it. Those of you who mastered (or at least became comfortable with) critical thinking in nursing practice will find that you will use it frequently in caring for your patients. If you don’t think you have good critical thinking skills — check out the next point
4. You Know More Than You Think You Do! — You survived nursing school, finals and the NCLEX test. Now you are dealing with patients on your own with no instructor staring over your shoulder. It is frightening, right? Sure it is, but have some faith in your self. You DID survive nursing school, finals, clinicals, hard and easy instructors, critical and well patients, and you did pass the NCLEX test. You know more than you give yourself credit for. Trust your well honed instincts and remember the basics: assessment, diagnosis, planning, implementation, and evaluation.

The American Society of Registered Nurses (ASRN.org) released the results of a survey this week looking at the reaction of RNs to the nurse staffing ratio law in California. In the article linked here, the authors say they asked 761 registered nurses questions on how the nurse to patient ratios in that state have affected their workplace.

The responses showed 56% believed they had more time to take a break during their workday and 69% thought the improved patient ratios have given them more opportunity to provide personal care for their patients. This seems to match up with the statements made by California Nurses Association President, Zenei Cortez in the recent interview here on the Nursing Show.

Nurse staffing ratios have become a big issue since the California law went into effect with nurses in many states attempting to pass similar laws. To date those bills have failed to pass and the article points out that in the other 49 states, it is legal for nurses to be assigned 10 or even 15 patients by hospital administrators and nursing supervisors.

This issue is not so cut and dried, though. With nursing staff shortages nationwide, where would the additional nurses come from in the short term as facilities competed with each other to maintain minimum legal staffing levels. California’s law caused a workforce shift of nurses into that state from other parts of the country as hospitals scrambled to attract enough nurses to meet legal requirements. What happens when these laws are more widespread and there are fewer nurses than ever to go around?

Don’t get me wrong. I think that competition is good for the nursing workforce as it will continue to push demand and wages higher for all of us, but in the short term — if these laws gain widespread acceptance, how can we expect facilities to comply with an impossible legal requirement?

Take a gallon bucket and a half gallon of water. You can require me to fill the bucket under the law, but if you don’t give me more water, there will be no way for me to fill that bucket no matter what the law says.

Got a comment? Let me know by leaving a comment below or by email at Comments@nursingshow.com

One of the hardest things in any nursing career is to develop good nursing job interview skills. I recently sat down with a group of recent nursing school graduates from the last few years to ask them about their experiences transitioning from nursing school to nursing job.

I’ll be featuring segments of this interview in articles posted here over the next few weeks under the category “career guide.” This segment looks at questions these recent grads had wished they had asked in their first job interviews. A wise person once said, “Those who refuse to learn from the past are doomed to repeat it.” Learn from the experience of those who have gone before and remember these 10 tips for new nursing grads when you interview.

1. Didn’t remember to ask any questions — The key word here is to remember! I can be the most scatterbrained person in the world sometimes. Especially when I’m in a new place and meeting new people. That is why I have become the list guy. Write your questions down and bring the list with you. That will show your prospective employer that you are organized and have a mechanism in place to get things done and not forget important tasks.
2. Ask about the salary — Some people think that talking about money and salary is in bad taste and they are right, when you’re at a dinner party. The place where it is in good form and even expected is in a job interview. A good interviewer should volunteer that information but may not if they think you already asked someone else. Ask the question! What do new nurses make? How are pay increases determined? What bonuses are offered for increased education or certifications? Is there a shift differential? How is overtime handled? These are things that you want to know before you go to work on your first day.
3. Nurse to patient ratio — What is the ratio of patients to nurses on the unit for which you are applying? This is important because the average nurse to patient ratio for the facility may be different than the ratio for your floor or unit. Also, ask about how that changes at night and what mechanism is in place when they are short handed.
4. Ask about health benefits — What is the health insurance plan like and how are the other health related benefits like dental, mental health, and life insurance? You may make $2 more an hour at one facility but your primary care co-pays are doubled. If you have a family or small kids, that $2 an hour can disappear fast!
5. Ask about perks for employees — Some facilities have become very creative in the ways they offer “value added benefits.” These are extras you get as an employee that don’t cost the facility that much per employee, but may be a great benefit to you. This goes beyond something like tuition reimbursement (although that’s a good one, too). It includes things like a workout room in the facility, or a gym membership, and even on-premises services like oil changes, dry cleaning pick-up and return, and personal shopper services.  These are just some of the extra perks that one hospital might offer to attract and retain employees.  When time is money, time saved is money saved and these types of perks might be valuable to you.
6. Ask questions about the nurse retention rate at 1 year and 3 years — This may seem like a loaded question but you can put it in terms of how they might be addressing employee concerns. Believe me, they know these figures. That is why they are out there hiring. Ask about employee input for change, opportunities for career advancement, learning opportunities, and open door policies with management.  What is this facility doing that addresses employee concerns?
7. What is the UAP ratio? Find out about how many UAP (unlicensed assistive personnel) are on the floor during a shift. This is as important as the nurse to patient ratio mentioned earlier. It doesn’t do any good if there is a 1 to 4 or 5 nurse to patient ratio when there are no techs or CNAs around to help with AM care and linen changes. Find out this number, too!
8. If there is a sign-on bonus — ASK WHY! The nurse recruiting rage for a while was for facilities to offer sign on bonuses to nurses as an incentive to come work there. Now this tactic has become a last ditch effort of some facilities to fill vacancies. But why do they have such a hard time filling jobs, even in a tight market? If they are willing to pay you just to walk in the door, you need to ask, “What’s the catch?” Now, I’m not saying that you won’t end up working there. If the money’s right and you go in with your eyes open, then you’ve made an informed decision. Just know the details going in.
9. What is the relationship between the doctors and nurses in the facility? Is there an institutional philosophy of mutual respect? This is a hot button for many nurses. Some nurses just accept that doctors don’t treat nurses very well and look down on the nurses with whom they work. I’m not one of them. I never let someone treat me disrespectfully and I refuse to work for a company that would allow that kind of abuse in their workplace. That said, I have had very few negative experiences like this and I believe that the tone of mutual respect and teamwork is the norm in most facilities, but it is important to know your rights and how a facility handles these things.
10. Ask to shadow a nurse for a shift — This falls under the category of LAST BUT NOT LEAST in this list. Once you’ve decided that you would like to work in a particular facility, do one more sanity check. Ask to follow a nurse on your unit around and shadow them for a day. Take the opportunity to see how the working relationships on the unit fit in with your style and find out how the policies outlined by your interviewer’s answers to your other questions work in real life. Other than talking about salaries, you can ask your shadow nurse just about any of the prior questions, too. This will give you the final piece you might need to decide whether this is the slot for you.

So that’s it! The top 10 questions new nurses forgot to ask but wish that they did as they started out their nursing careers. Just remember, it’s an open nursing job market out there. Your dream job may turn out to be something totally unexpected. Ask these questions to help you get there sooner and congratulations on graduating!