Back to the Bedside
Useful tips for taking a nurse refresher course.

By Michael Bratton, RN, MA
December 13, 2004

Never has there been a better time for returning to bedside clinical practice. As groups like Nurses for a Healthier Tomorrow have pointed out, the current nursing shortage is projected to continue for several years. As a result, the U.S. Department of Labor Bureau of Labor Statistics lists nursing as the top position for growth. (For more information, visit http://stats.bls.gov/oco/ocos083.htm.)

Maybe you left nursing to raise your children and now it’s time to return. Maybe your financial situation has changed because your spouse has been laid off. Maybe you left nursing for another career and now want to return. Maybe other nursing opportunities have led you away from the bedside and now you want to reenergize by taking care of patients. Or maybe you’re on your own again after a divorce. All of these were reasons given by the 14 nurses in the nursing refresher course I took.

As a nurse for more than 25 years, it was time for me to take care of patients again. Although I’ve enjoyed my recent years as vice president, patient care services and chief nursing officer at BryanLGH Medical Center East in Lincoln, Neb., I’d been moving further and further away from the bedside. So, to get up-to-date in bedside clinical practice, I enrolled in an RN/LPN refresher course at Southeast Community College in Lincoln. Thanks to that course and some additional continuing education offerings, I feel prepared to reenter the world of bedside practice.

Taking the refresher course was a worthwhile experience, and I learned as much from the other students as the instructor. Because I kept a journal during the course, I have some suggestions for getting yourself back to the bedside. After all, there has never been a better time.

Choose the right course

• If you have a choice, look for a program that combines classroom lectures, a skills lab, clinical time with a preceptor, and computer-simulated learning.
• Take a course that prepares you for licensure in your state. Some state boards only accept courses they have approved. You will probably need a temporary license during the course.
• Colleges or schools with nursing programs often will let you use the same computer simulations as their regular students. Be sure to take notes during the computer simulations. Given the frequency of computer use in most facilities, using the computer simulations will be good practice for you.
• Don’t be afraid of a class that combines RN and LPN students. It’s a great opportunity to learn roles and gain empathy.

Hit the books and the sites

• Subscribe to a few clinical nursing journals or check them out at the library.
• Visit your state board of nursing’s website because it has important information about relicensure. In addition, many websites, such as www.nurseweek.com, have topics about clinical issues and practice updates.
• Keep up with your class reading assignments before each class; that way, you will get more out of the content that is taught.

Attitude is everything

Being open-minded is a great way to learn new things. For example, be willing to work some night shifts and weekends in your clinical experience. Often, facilities have many students on day shifts and their preceptors are occupied with new employees of the facility, which may limit opportunities. Working nights and weekends helps the facility and conveys an attitude of willingness that may help you with future employment opportunities.

An added benefit is observing how the shifts integrate. For example, it is common practice for the daily medication administration record to be printed on the night shift and validated by the night shift nurses. You may not learn this if you only experience the day shift.

Other attitude adjustments you should make are —

• Practice humility. Don’t feel compelled to talk about your past experience; focus on learning about today. Avoid asking preceptors “why” they do certain things. These kinds of questions can make people defensive. Instead, ask “Is there anything else I should learn about this?” or, “Tell me more about how to address this.”
• Don’t just observe in the skills lab. Rather, be sure to practice skills in the lab with your instructor and other students. If you haven’t taken care of patients in awhile, you need the practice.
• Learn on breaks. When you’re in your clinical with a preceptor, join other team members from the unit for meals. You can learn much from the unit secretary, nursing assistants, and therapists.

Work with your preceptor

• Try to get a preceptor who works where you might choose to work. You should meet with the preceptor as soon as possible to complete the paperwork required by your course, as well as the preceptor’s agency.
• Use a checklist of the key skills you want to accomplish with your preceptor. Be sure to review the facility’s policies and procedures before performing skills. Many times you can print these from the facility’s computer.
• Ask for a packet of the most common charting forms so you can review them in advance. These often are already assembled in a new patient admission packet.
• Work your preceptor’s schedule. Initially, try to arrange a day off between shifts so you can look up information. Later, be sure to work a few days in a row if possible. And, work some full shifts so you get the whole picture. Attending change-of-shift reports will help you and your preceptor identify opportunities for practicing skills with other nurses and patients.
• Understand that your preceptor may teach you practices that are different from what your instructor teaches you. Make sure to focus on the principles, not just the task.
• Remember the saying that leads to mastery of skills: “Watch one. Do one. Teach one.”
• Read the facility’s communication bulletin boards. You will likely gain up-to-date clinical information and may even find a job posting you are interested in.
• Don’t accept a patient assignment. You need to be assigned to the preceptor and her or his patients.

Get the right look

Your preceptor probably can provide information about what to wear. If you will be doing clinicals in multiple facilities, consider white. Today, most facilities are more accommodating than in the past and allow a variety of uniform choices. Most nurses wear walking shoes or tennis shoes and not every facility requires white. But get a pair that can be wiped clean — nurses still encounter plenty of spills.

You also should ask about discounts for students at uniform shops. You may receive a lower price if you are doing clinical at a facility where the employees receive discounts.

Explore other learning opportunities

Many hospitals, nursing homes, and home health agencies have ongoing education inservices, and these are sometimes open to nonemployees. Ask to be put on mailing lists for continuing education. These courses are often available at student rates, so take them while you are registered for the refresher course.

You’ll also want to take a CPR class. Some refresher courses will require this as a prerequisite.

Most refresher courses are based on adult learning principles. Many times the students can learn from each other. If you have the opportunity to teach a part of the class, choose a topic based on an area of high interest. Another option is to teach something with which you have had personal experience. Several of my classmates used this approach. One, the recipient of a liver transplant, taught us the latest nursing care for his condition. Another had cataract surgery during our semester and talked about the importance of patient teaching.

Keep a journal and develop a calendar

• Record your thoughts, feelings, hopes, and fears, and bring them up in class. You will be pleasantly surprised how many other classmates have the same concerns .
• Keep track of things about which you want to get more information. Write down some of your experiences and the key points learned.
• Keep the class syllabus and course outline. It will come in handy for future job interviews. Incorporate it into your continuing education profile.
• For your calendar, you should include classes, tests, reading assignments, and clinical days. Integrate this with your personal calendar for work and home.

Celebrate the small victories

• Sometimes the little things make a big difference. Organize with other students for bringing snacks for class. These classes can last as long as four hours, and the snacks help keep you going.
• Applaud when other students give presentations. A little support can go a long way, so ask for each other’s references and get each other’s e-mail addresses and phone numbers.
• Arrange for a class reunion sometime in the six months after the class is complete. Make sure you pick a date and location, such as a local restaurant, before the course is over. If you don’t, you may never get together because of the difficulty of contacting everyone.

Going back to the bedside after a prolonged absence isn’t easy, but the greatest triumphs come from defeating adversity. If you’re ready to return, the bedside nursing is waiting for you. The timing couldn’t be any better.

Important clinical updates

Listed below are some of the more significant changes that have occurred in bedside practice in the past 10 to 20 years.

Two forms of patient identification are used for medication administration or other procedures. This is usually the patient’s name and birth date.

Hand hygiene is practiced with traditional hand washing or new alcohol-based hand rubs.

There are now six rights to medication administration. The previous five, right drug, right patient, right time, right dose, and right route, have been supplemented by a sixth — right documentation of the medication and the patient’s reaction.

The use of restraints is limited — restraints are used only after other nonrestraint methods are exhausted.

Skin breakdown is treated with protective and occlusive moist dressings. Heat lamps are no longer used.

Lemon and glycerin swabs are no longer used for mouth care.

The terminology for classifying seizures has changed.

Many abbreviations are now considered unsafe and are discouraged. Some examples include —

• Use the word “daily” instead of “q.d.,” which can be misread as q.i.d. (four times a day).
• Use the word “units” instead of “u,” which can be misread as a zero, causing overdose.
• For doses of medications that use decimal points and are less than one, use a leading zero (e.g., 0.25 mg, instead of .25 mg) so the period is not misread.
• Trailing zeros should not be used. For example, 2.0 could be misread as 20 if the period is over looked. Instead, use just the number 2.

It is now common for the patient’s temperature to be recorded in centigrade and for weight to be recorded in kilograms.

Pain assessment is considered “the fifth vital sign.”

Mercury thermometers are no longer used.

Tighter blood sugar controls are sought in treating diabetes mellitus.

Nearly all IVs are administered on pumps.

Many more medications come in sustained release form and should not be crushed for administration.

Normal saline is used to flush most central lines and capped peripheral IVs, instead of heparin.

The use of the term “protime” for blood monitoring during coumadin therapy has been replaced with a new term, “INR,” or international normalizing ratio.

The ventrogluteal injection site is preferred over dorsogluteal. When choosing landmarks for dorsogluteal injections, the use of the intersecting horizontal and vertical lines to identify the upper outer quadrant is no longer encouraged because of the risk of sciatic nerve damage. Instead, an imaginary line is used between the greater trocanter of the femur and the iliac crest.

Floor stock multidose vials are discouraged for heparin and potassium because of the risk of misreading the bottles when normal saline is needed.

Michael Bratton, RN, MA, has more than 25 years of nursing experience in clinical and leadership roles. He has practiced in acute care, critical care, home care, and rehabilitation, and has experience as a staff nurse, nursing manager, nursing director, and most recently as vice president, patient care services, and chief nursing officer at BryanLGH Medical Center East in Lincoln, Neb. Bratton recently went through orientation to work as an ICUstaff nurse at BryanLGH.