The scene repeats itself over and over. It’s 2:30 am, monitor alarms ring at various pitches, the hum of the ventilator drones rhythmically and nurses perform their synchronized, yet frenetic dance between patients. I was fresh out of nursing school, working in the surgical intensive care unit of an urban academic institution. I had chosen critical care for my senior year clinical rotation and decided immediately that was my calling. I thought I was ready but was hit with a harsh reality in the first few weeks on the job - I was not prepared at all. There was one patient in particular that brought this fact to light. I was working night shift and my patient Mr. C. was recovering, post-operative day five following a colon resection to remove a tumor. Mr. C. had failed to wean from the ventilator due to his chronic emphysema. That night his blood pressure and temperature slowly drifted downward. His skin cool and clammy, I continued to monitor his vital signs closely. His blood pressure hovered in the low 90’s systolic and his temperature dipped to 96.1 degrees Fahrenheit. I was focused on making sure my medications were administered on time and that I was performing all the required tasks to get through the night. The next morning during rounds the provider on-call was furious. Mr. C. was developing septic shock and I was rebuked for not notifying him earlier that night. Short-staffed, my preceptor had been assigned her own patients and was unable to provide enough oversight for me. A fluid bolus was ordered, blood cultures and a lactate were drawn, antibiotics and a vasopressor would be administered next. I left work that morning angry and upset that I didn’t recognize those subtle signs of sepsis earlier in my shift, when time to treatment significantly impacts patient outcomes.
This scene plays out in hospitals across the country and around the world. New nursing graduates begin their careers armed with a significant amount of information, but little if any clinical judgment. In the recent report entitled Closing the Education-Practice Gap: Building Confidence + Competence,
Dr. Anne Dabrow-Woods and Julie Stegman discuss the results of the New Nurse Readiness Survey conducted by Wolters Kluwer. The authors state that new graduate nurses are not fully prepared for practice due to “gaps in nursing practice … attributed to ineffective communication, the complexity of the clinical environment, lack of knowledge about patient care, and lack of experience working in teams” (Dabrow-Woods & Stegman, 2020). They go on to state that students need to apply their knowledge, think critically, and use evidence to make good clinical decisions (Dabrow-Woods & Stegman, 2020).
Many nurse educators in academic institutions have access to new technology and training tools to instruct students. However, educators in the clinical setting view new graduates as too heavily reliant on technology preventing them from applying their knowledge in clinical practice. Dabrow-Woods and Stegman (2020) outline several strategies that academic nurse educators and clinical nurse educators can implement to better prepare nursing students for the workforce. These recommendations are summarized in the following table.
||Nurse Educators in Practice
|Understand the challenges experienced by practicing nurses and incorporate these into nursing curriculums in addition to the essential competencies.
||Develop a standardized transition program or residency that helps new nurses adjust to clinical practice.
|Incorporate a clinical judgment model using active learning strategies such as simulation.
||Consider dedicated education units (DEUs) that support the transition to practice.
|Include a case-based approach within the curriculum supporting the use of evidence to make clinical decisions.
||Develop onboarding/orientation programs that decrease time-to-productivity of new nurses.
|Integrate virtual and simulated learning scenarios that help students identify and interpret patient cues, prioritize problems, implement solutions, and assess outcomes.
||Institute a nurse orientation with preceptorship programs that gradually build a new nurse’s skill set and responsibilities based on demonstrated competence.
|Individualize learning using adaptive learning techniques that can be personalized based on the student’s performance.
||Incorporate blended learning into orientation including an evidence-based curriculum.
[Reference: Dabrow-Woods & Stegman, 2020]
Later in my career, I had an opportunity to work for a medical education company that developed a simulation platform for critical care nurses. We crafted patient cases and integrated mannequins and monitors to emulate the intensive care unit. Users would assess vital signs, adjust oxygenation, titrate intravenous drips, and administer medications virtually. Every action was captured in a database which could be downloaded to evaluate an individual’s performance. Students could hone their critical thinking skills and veteran nurses could complete annual competencies, including basic life support (BLS) and advanced cardiac life support (ACLS) certifications. This risk-free environment allowed new graduates and staff to make mistakes, learn from them and build confidence.
It’s been over 25 years since I graduated from nursing school. Technology has had major impacts in our lives over these years and in nursing education, the use of simulation can increase nursing students’ ability to see the big picture faster. This includes putting together subtle signs and symptoms that when viewed in isolation might not seem harmful, but when pieced together, they allow providers to intervene promptly. We have an obligation to properly prepare the next generation of nurses so that they have the skills necessary to care for an ever-increasing complex patient population.
Dabrow-Woods, A. & Stegman, J. (2020). Closing the Education-Practice Gap: Building Confidence and Competence, New Nurse Readiness Survey. Wolters Kluwer.