Experienced Bedside Nurses: An Endangered Species?

“The trend toward our hospitals being primarily populated with nurses with less than two years’ experience is worrisome.”

At least three colleagues who’ve recently been patients in hospitals or had family members who were have remarked on the youthful nurses they encountered—and on their lack of experience. In two of the conversations, my colleagues cited instances in which this lack of experience was detrimental to care, one of them dangerous. That “sixth sense,” that level of awareness that comes with lived experience and becomes part of expert clinical knowledge, is important for safe, quality patient care.

In the February editorial, I report on the answers I received when I queried our editorial board members about new nurses’ inclination to work in acute care for only two years to gain experience and then leave to pursue NP careers. Many of the board members have seen a similar trend, one reflected by research on nurse retention, some of it published in AJN (most recently, see Christine Kovner’s February 2014 study on the work patterns of newly licensed RNs, free until February 6).

As one board member noted:

“The narrative must be shifted to embrace the full range of roles and contributions of all nurses. Our health care system depends upon a well-trained, experienced workforce. The trend toward our hospitals being primarily populated with nurses with less than two years’ experience is worrisome.”

It’s a complex issue, and no one is faulting new RNs for the career paths they pursue. But as this trend accelerates, what can be done to ensure that there are enough experienced nurses at the bedside to protect patient safety? Let us know your thoughts.

Editor-in-chief, AJN

16 Comments

  1. Sean February 18, 2018 at 11:29 am

    Except for CRNA ED and ICU nurse make more life and death decisions then most higher level more educated nurse out there, but the pay and respect is not there. It take 5 years to grow a critical care nurse to be an expert! The floor nurse are just killed with work load and flow issues. I don’t blame any nurse for getting off the floor soon after they arrive.

  2. Janet martiniccho February 18, 2018 at 9:36 am

    Iam a diploma grad with a BS,45 yrs and still going strong.I worked med/surg for 10 yrs. We had mentors and we did team nsg,which in my opinion was the best.we worked with excellent lpns and aides and we all learned from each other and learned to work as a team .I don’t think nsg works that way anymore due to primary nsg.”it’s not my pt” is frequently heard throughout the halls. (Boy iam really showing my age here).I became a nsg manager for 7 yrs and I was a working manager.when they told me I would become strickly administration I left and worked ED for 30 yrs again with a mentor. That’s the magic word MENTOR. Just saying

    Janet
    Works asu and still loves being a nurse!

  3. Amanda Golino February 5, 2018 at 9:32 pm

    I’ve been fortunate in my career to work for organizations that support the professional practice of nursing, and I know that that is not true everywhere. I think it’s great that some of us choose to become NPs, but I also think many nurses don’t know how many other options there are out there when they are looking for other opportunities.
    Look into nurse educator programs. Most nursing programs desperately need instructors.
    Look into informatics. We all have EMRs. We need nurses to build these and make them better.
    Consider politics. Nurses generally don’t advocate well for ourselves. We need to be more vocal, and visible. I believe a nurse would make a fantastic politician-look at what we navigate every day!
    Look into the Clinical nurse specialist role. I am a CNS and have found it to be a truly challenging and rewarding role. I nurture, mentor, support and advocate for nursing every day. I have a job I love, and there is a huge demand for our role.

  4. Penelope Steele January 30, 2018 at 7:27 pm

    As a nurse if 43 Years I have witnessed much change in nursing. I have read all of the aforementioned comments and have a few to add. In the “old” days our education was hospital based. When I graduated Diploma Grad… I had experience in Med surg critical care, charge nursing, and critical thinking skills which I can currently rely on when informatics collapse … the computers are down again. I had numerous opportunities in nursing that required higher education. Pursuing both a BSN ans MSN in a brick and mortar classroom. I hurts my heart to watch as students valuable clinical time is one of “observation” as clinical instructors drop them in a unit with no set objectives. I have also been a clinical instructor who gave rich clinical opportunities and requirements. The assignments I gave I would readily do myself.

  5. Wendie Howland MN RN-BC CRRN CCM CNLCP LNCC January 30, 2018 at 1:37 pm

    @JUlleit, thanks. At the risk of again sounding like an old bird and using words I swore would never cross my lips, “in my day” ::sigh::, when I went to college right out of high school only about 5% of RNs got their basic education in a BS program (I did, because my family is chockablock full of highly educated folks and it was an assumption since forever that we would all go to college), so when we new grads all went to work, we stayed there. Later, when I got my MN, the proportion was about the same– 5% of RNs had masters degrees. While I did end up with a clin spec job after a few years, I continued to work bedside for some time after defending my thesis (from a real school, with a real research project required).

    However, now in my work as a legal nurse consultant I am regularly challenged in deposition by opposition counsel who assume I got a masters degree online from someplace that took pretty much everybody, and their money with no real accountability for outcomes– because that is what they see. It’s very irritating to have that assumption thrown in my face when I went to a really good university and worked hard for it, had to show my face in seminars and classes every day, teach some, and had two department heads and two future deans on my committee and on my butt making sure I did good science.

    If the currency of advanced degrees suffers from inflation because, like a treasury, too many pieces of paper got printed, then we all will suffer, if not by association then when we’re in the beds ourselves. Then employers, and the general public, will have some reason to think that, still, nurses aren’t very smart or they would have gone to “real” education, and that we remain angels and caring medical appendages not worth paying more. And perhaps the best and the brightest will leave the bedside. But I still have confidence that there will be enough of them left to do the job and perchance even to excel. Sometimes people get woke later in their lives.

  6. Erica B. January 30, 2018 at 1:26 pm

    I think hospitals should actually offer more externship/mentorship programs for new nurses.These programs can provide invaluable learning experiences for new nurses however they are highly competitive and often have a very limited amount of spots open. You learn the foundations of nursing in school but in reality you don’t truly learn how to become a nurse without hands on experience. I have recently graduated from an ADN program which accounts for very little in the city I live in because no hospital will hire nurses with only an ADN. I am currently pursing my BSN but whether you’re a new nurse with an ADN or a BSN, in many instances you still have very little experience fresh out of nursing school. Experience comes with time and practice and more hospitals need to be willing to provide these opportunities for new nurses to gain this experience. Orientations vary widely among hospitals but maybe extending them will ensure that new nurses start off on the right footing which shows that hospitals are invested in their new nurses doing well.
    It’s frustrating because as a new nurse its hard to find a job with very little experience. Hospitals want skilled nurses but how are new nurses suppose to get this experience with limited opportunities available?

  7. Barsha January 30, 2018 at 10:08 am

    Stephanie I completely agree with you. Bedside nursing is becoming disrespectful profession and stress level is rising higher and higher. Pay is not worth what we do. We don’t get any support from higher level and expectations are very unrealistic.

  8. Stephanie Frederick January 29, 2018 at 6:40 pm

    There are several problems contributing to this phenomena:

    1) Bedside nursing and hospital expectations are not realistic. Nurses are swamped with numerous tasks, procedures and protocols on top of unsafe patient ratios and are not supported by upper management. Their frustration builds as their voices aren’t heard, and leads to high turnover, whether it would be leaving the profession all together or seeking higher education. If hospitals would mandate safe patient ratios and actually keep them, it would be a stepping stone. Also, for the amount of work and liability that are on nurses’ shoulders, they should be compensated accordingly.

    2) During my BSN education, I was told in every single class to obtain an advanced degree. This is not an exaggeration. What is stemming from this encouragement could be experienced nurses counseling new nurses to avoid the abuse they will soon be experiencing, or it could be that nurses still feel that their opinions are vastly unappreciated in the healthcare field.

    3) Stemming from the previous sentence, in order to feel more appreciated, nurses will often seek positions that will offer them a heard opinion, such as a CRNA or CRNP.

    4) With the surplus and uncontrolled amount of online and for-profit nursing schools, nurses can obtain an advanced degree as quick as possible and leave as quickly as possible. Oftentimes these types of programs do not require any nursing experience, do not maintain credible methods of tracking the quality of clinical experience the students receive, and literally accept almost any applicant to receive the tuition money. CRNA schools do not follow this suit, thankfully.

    As a nurse that left the bedside after three years, I can honestly state that all these reasons and more were applicable to me, with the exception of #4. At one point on a telemetry unit on night shift, I had 10 patients and no aide, and that was the normal occurrence. Upper management did not listen to the staff nurses’ concerns for liability, patient safety, nurses nearly passing out due to inability to eat, drink or use the bathroom over 12-14 hours, improper patient placement or patients hitting and abusing the nurses. So, naturally, an exodus is occurring, and everyone is asking why.

    I wanted someone to listen to my educated opinion and actually respect it, not cast it off and say, “Whatever, you’re just a nurse.” I was tired of sacrificing my health and my sanity for almost nothing in return. So, I left, went to a respectable graduate school, and now am a nurse practitioner.

    If you want to keep nurses, listen to them, and actually do as they requested. Also, change the accrediting criteria for nurse practitioner education. The quality of the students graduating from these programs are embarrassing and dangerous, and are not helping the profession as a whole at all. If you want respect, act respectable, and not desperate to show off how many nurse practitioners there are in the United States.

  9. Shannon Allen January 29, 2018 at 4:47 pm

    To address this matter, I think it is important to truly understand the relationship between experience and effectiveness. Is our value of the “sixth sense” and aggregated knowledge part a paradigm that we should challenge? For me the answer is yes! We need to define the future of nursing with consideration of technology transformation in healthcare. Advances in analytics, IoT, and cognitive will impact the role of the nurses, reducing the importance of knowledge-gathering as foundation of effectiveness. Nurses have the opportunity to modernize the role we play, making technology one of our partners in patient care and advocacy.

  10. Jan Ulleit January 29, 2018 at 4:36 pm

    Thanks for this important discussion. W Howland correctly comments here that not every novice RN can become an NP, Informatics specialist, CRNA, or such. True, but in my narrow world, I have watched many of the quickest thinking and most caring nurses in my 2009 class leave hospital bedside nursing to pursue NP, CRNA, MBA and even PA degrees. They stood out both for full understanding of the material and being leaders. They are now working as NP clinicians, hospital management, an Epic trainer, an analytics specialist, and even a yoga teacher/life coach. Very sadly, the preponderance of my class still at the bedside tended to be the weaker students of our class.
    If my small sample is even partly reflective of the bigger trend, it’s not good! When those with the most initiative, confidence, and multiple skills choose to flee our hospitals disproportionately, it’s a cry for much needed change.

  11. Rachel Short January 29, 2018 at 3:26 pm

    Hi – Great Article !

    I’m a ten year ASN nurse currently pursuing my MSN in Nursing Informatics. I’ve been working as a nurse for a decade with the majority of my career spent at the bedside working on busy med-surg units across the Southeast. I just spent a year as a travel nurse working on different floors in a large hospital in Tennessee and I can attest to the truth of this article. Every floor I worked on was primarily staffed by new grads and/or nurses with less than a year of experience. These new nurses are just trying to get their year of bedside nursing experience before moving on to something like Critical Care or NP school.

    New nurses have many wonderful attributes : Idealism, Eagerness, Current knowledge about best practices, and they are often far superior in computer skills and their understanding of human-technological interfaces . BUT when the majority of a unit’s staff is inexperienced it creates unique challenges for the experienced nurses who work alongside new nurses. The experienced nurse may be frequently asked to perform or assist coworkers with skills and to precept new staff. The experienced nurses may also be expected to take on higher acuity patients or be the first to float other units.

    With a staff of inexperienced nurses, there’s also the issue of patient safety. There’s no accounting for experience and I agree with this author’s point that a nurse’s sixth sense and instincts are earned over a career and cannot be taught in school.

    One important point to take away from this article is why are new nurses fleeing from the bedside in droves ? Are all of the nurses coming in with the attitude that “I’ll do my year of med-surg and pay my dues before movng on to my real career?” . Perhaps. It might mirror the way physicians are rejecting general practice in lieu of a career in a more specialized field.

    But I also believe many new nurses are being driven away by the stress and poor work conditions for bedside nurses (especially in states without a Union). As mentioned in a comment above, when looking at the lack of experienced bedside nurses, we need to consider the many factors (workload, staffing, pay,) that make bedside nursing a less than desirable job.

  12. Charles Sancho January 29, 2018 at 2:55 pm

    Bedside nurses aren’t paid enough, so of course, they leave to pursue higher education and opportunities to make more. After all, we too, have families to provide for and deserve to be paid a good salary for the hard work we put in. I have friends with Bachelor’s degrees in liberal arts, etc (working outside of healthcare of course) and have much better benefits, get bonuses, and make alot more (and even get raises! wow! what a concept!). So, it becomes very frustrating for me. I’m an experienced ICU nurse of 12 years. I will be pursuing another degree this year too.

  13. Wendie Howland MN RN-BC CRRN CCM CNLCP LNCC January 29, 2018 at 12:28 pm

    This reminds me of the old George Burns joke. George goes to his physician and says “Doctor, I’m so upset. My neighbor, he’s 87, and he says he has a different beautiful woman in bed three times a week, having wild passionate sex. What should I do?” And the doctor responds, “Well, George, you can say that too.”

    Many older nursing faculty remember when 90% of our incoming Cherry Ames wannabes were dead certain sure they would be “mother-baby nurses.” Well, obviously, that wasn’t going to happen. Even if the market for OB nurses wasn’t fairly finite, most of those students found they fell in love with other kinds of work. Else who’s taking care of everybody who’s not parturient? Even if new grads still yearned for the del room, they ran up against reality: Want a job? This is what there is. Take it or leave it. Generally, they took it.

    Now they all want NP or CRNA school.

    Call me a cranky old bird, but I find it difficult to get fluffed up over the present trend as described. All new grads who plan to work a year or two in critical care or ER and then go to CRNA or NP school (and their hand-wringing undergrad faculty) should remember that ERs and ICUs are not hiring new grads in vast numbers. (I understand now the average wait time to get hired in some places is over 18 months— for ANY job.) After that, their competition for the limited number of spots in those graduate programs includes a lot of RNs with a decade or more experience. So newbies who are barely getting to the point where they can be called competent (not expert) may be in for a tough reality check.

    Then there’s the problem of getting clinical hours. Many programs leave it to their students to locate and secure their own clinical placements, and this is not as easy as waltzing into the nearest clinic and showing your smiling face. They whined about how hard it was to prep for the NCLEX was? And then there’s the problem of getting a job … while you still work staff because you can’t find one.

    And don’t let’s even start on the profusion of sketchy online programs promising these aspirants a whole new way to practice that doesn’t involve the messiness of bedside care, shift work, and dealing with your family who always thought nursing was somehow inferior to med school. The grads from these are really in for a shock, and not just when the loan payments come due.

    So, let them say that’s their plan. That’s OK. Faculty do have some responsibility here. I applaud those who consider it. Now they would do well to include some basic economics in the syllabus (unless their programs require a full semester of economics, as my undergrad program did). If not, those students will come up against market forces soon enough. There’s a case study in there that everyone can appreciate.

  14. Teresa Hale January 29, 2018 at 11:45 am

    While nurses are being strongly encouraged to obtain advanced degrees, the culture, pay and practices do not seem to support advanced degrees at the bedside in clinical roles. I recently stepped out of a management role to go back to school. I completed my MSN and wanted to step back in to a clinical role for a while to re-energize with the rereadons I became a nurse and decide on my next path. As a nurse with 30+ years experience, many questioned my choice, and I have found that the struggle to find realistic shifts, paced and pay for bedside jobs, even for experienced nurses is real. I found myself accepting less pay to work a more physically demanding job and having others question why I would choose to ever be back at the bedside. In all reality, I see myself stepping back into a management position in the near future, simply because I do not feel as valued for my education and experience at the bedside. I would rather have the mental stress if leadership than the physical and financial beat-diwn if the bedside role. I hate this for nursing.

  15. Michaela January 29, 2018 at 11:35 am

    As a new ADN graduate, I find it so discouraging that hospitals are refusing to hire ADN nurses in favor of BSN graduates. We have the training and education needed to become excellent floor nurses and yet, hospitals turn us away. While I agree that obtaining higher education for nurses will benefit the nursing profession as a whole, I don’t agree with restricting the educational routes for future nurses or forcing all nurses to obtain a BSN degree to be considered competent in their care. The nursing profession is such that bedside nursing experience is perhaps more important than a degree – yes, it is a science, but also an art. It is a hands-on profession and I think an ADN nurse with years of experience is more advanced than an inexperienced BSN graduate.

    In addition, ADN programs are important for people who want to become nurses later in life, for those with families, or those who cannot afford a BSN program. BSN programs favor traditional undergraduate students. ADN programs keep the nursing population diverse and rich with experience. There should NOT be a push to fade out ADN programs, but the opposite; I think that promoting ADN degrees would create a more diverse, experienced workforce and increase the number of bedside nurses.

  16. Amy Gentry January 29, 2018 at 10:29 am

    In my opinion, bedside nurses are being abused in terms of workload, staffing, and nurse-to-patient ratios. Once this reality sinks in, they want as far away from the bedside as possible. We need to ensure tolerable workloads that will allow new nurses to flourish and enjoy nursing. This will improve nursing satisfaction and lead to less of a push to get away.

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