Improve On-The-Job Training For Nurses
By Donna Setterholm, MA in HHSA, BSN, RN 05/31/2024
Sometime in the mid 1970’s, health care facility executives decided to eliminate on-site departments of nursing education, laying off all nursing educators. These educators had been responsible for training new graduates to ensure the application of proper principles and techniques/skills. They were also responsible for training all nursing staff regarding new equipment acquired and their proper utilization and procedures.
While that decision was made, nursing schools/colleges decreased their clinical practice time preventing comprehensive application of their educational content and concepts. Academia began relying upon the health care facilities to orient and train new graduates. These new graduates were being trained by “preceptors” on the given nursing units within a 6 month to one year period of orientation. These orientees were often assigned to care for less complicated cases, and therefore, did not learn the more complex procedures. Or an opportunity to learn many procedures did not arise during the orientation period. Most of these new graduates were expected to “solo” at 6 months regardless of their training and may have had to care for more complex clients subsequently.
Once a nurse is off orientation, an inexperienced nurse may be assigned to clients that require procedures that the nurse had never performed or even observed. Some nurses will ask a more experienced nurse to show them how to do the procedures. But some will “wing-it” and perform the procedures by “guess and by golly”. How would you like to be the client that gets those later described nurses?
Often clients with the most complex care needs and procedures are assigned to the more experienced nurses, who then may not have time to train others. They already have a heavy workload. These seasoned nurses may feel guilty that time management prevents them from helping their new co-workers. And the co-workers may view the seasoned nurse as uncooperative or even nasty. The dilemma: younger nurses1 become hostile toward older nurses and older nurses become critical of the younger ones. Hence, the quote: “Nurses eat their young” was established.
The reality is that the gap in nursing education and training allows for incompetency of nursing assessments, procedures and skills. There is a lack of adequate and proper transition from student to professional development.
Compounding the problem is the fact that hospital or facility unit “preceptors” are not vetted to be sure they are teaching proper procedures and techniques. Sterile technique is more than a ritual to get a job done. It is a mind set that must be taught through supervisory observation of technique so that sterility is maintained. Yet, some preceptors I have observed break sterile technique while inserting foley catheters. I also witnessed a “veteran AD preceptor” instructing a BSN new graduate to mix TAP water with Protonix for IV injection. I pulled that new graduate aside and asked her how she was maintaining a sterile solution for injection into the blood stream using tap water. She responded with, “My preceptor told me to do it this way.” I told her to never go against the principles she learned in school. I showed her how to do it properly with sterile saline. She was caught a few years later mixing tap water for IV injection medications.
There has been an increase in urinary tract infections and sepsis, plus other hospital acquired infections due to inadequate training and supervision, particularly of sterile technique. We need to utilize experienced, vetted nurses to improve the quality of nursing care. These qualified educators need to be free to train, being called upon when a nurse, no matter how experienced, needs on-the-spot training. Re-institute qualified positions of clinical education with supervision. Do not replace hands-on training needs with e-training. Computer education works well for presenting concepts or content, but it cannot replace actual application of content without supervisory training. Provide a cell phone or pager for vetted, seasoned nurses to respond to training requests in real time and need.
In some facilities, retraining to eliminate “old” habits may need to be instituted. We definitely need retraining of sterile technique. We must recertify BLS every 2 years. Why not be required to recertify for preventing hospital acquired infections which occur more often than we use BLS.
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1. Younger means fewer years of experience. Many new graduates are older in age but are young at their nursing job. People in their 30’s through 60’s are re-careering into nursing.