November 25, 2007, 3:45 pm

Clinical Competence – Where Did YOU Rate?


My colleague here is pouring something, but she sure looks apprehensive about the whole thing!

I think I looked like that for the first two years after graduation. Heck, I may still look like that and no one has the heart to tell me!

Now, this cap is a 9/10 on the Emergiblog Cap Rating Scale. The only thing keeping it from being perfect is a solid black strip running across the cap approximately one inch from the top border.

My cap is pretty nice with its green and gold stripe. I just wish I could wear it without getting razzed to death. You can hear the smirks across the Bay!


Speaking of nurses and graduation, how much clinical time do you believe is required in a nursing program to produce a competent, functional registered nurse?

We all know that the hospital-based diploma programs were jammed full of clinical time, with the student nurses essentially used as staff nurses on the wards. Those days are gone, and nurses are now educated in colleges and universities.

So, are new nurses getting enough clinical time?


What is more important to focus on in nursing courses: the clinical or theoretical? Should nursing students be proficient in clinical skills on graduation and learn theory on the job? Or should they be steeped in theory and learn to think critically in school followed by learning the technical aspect on the job?

Is there time in a nursing program to address both of these aspects of nursing effectively?


As an ADN grad, I did not feel that I had enough clinical time to become proficient in the technical aspects of nursing care before I graduated. I’m talking foley catheters, naso-gastric tubes, monitors, IV starts, etc. It may just have been my youth and insecurity, but I was scared to death when I graduated. No one cared that you could spout the adaptation theory of Sister Callista Roy by heart and backwards. There was work to be done.

I would say that you cannot do everything in two years, yet my BSN colleagues had even less time at the bedside than I did.

Then there are the programs that allow people with previous experience in a medical-related area to become an RN through a program that condenses the entire clinical experience into a two-week period. Two weeks? Medical, surgical, OB, pediatrics and psych in two weeks?


I’m interested in what you thought of your nursing clinical education. Did you feel prepared to take on the clinical tasks right after graduation? I put in one foley and one NG before I graduated. No IV starts. No training on monitors.

What are the clinicals like out there now? How many hours a week are you actually at the bedside? How many chances are there for you to do procedures? At what point do you take on what would be considered an entire “assignment”? Do you take report and give report? How involved are the staff nurses involved in your clinical education?

And, if you became an RN through one of the distance-education programs, how did you fit in your clinical experiences?


I’m asking from the perspective of someone who is considering going into nursing education. If you are a nurse blogger, write a post about your clinical experiences. Current students and those who were students when the Summer of Love was not a distant memory – let’s compare!

Send the posts to me and I’ll put them in the December 13th issue of Change of Shift.

Have things really changed over the last few decades?

Inquiring minds (mine) want to know!


  • Nurse K

    November 25, 2007 at 4:54 pm

    We had A LOT of clinical time in our BSN program. 13 weeks each (1 day per week + 1 lecture) of: long-term care (always the first clinical), med/surg, peds, OB/GYN (separate from peds), psych, public health, and a 1-month (40 hrs per week) internship in either surgical, critical care (I chose critical care), or emergency. The hospitals also have paid nurse internship programs where you’re paid $12/hr to hang around a nurse and learn (do everything, basically, under their supervision). I did this 3 shifts a week for 6 MONTHS.

    I felt pretty confident after I graduated, but there is still a big learning curve, especially with the time management portion. If I’d not done my neuro paid internship, I’d have never had more than 2 patients at once. Going from 2 patients to 8 surgicals on night shift post-surgical really, really, really sucked, but I think it sucked for everyone, including the seasoned nurses.

  • Nurse K

    November 25, 2007 at 4:57 pm

    I should say that we had a separate class called “critical care nursing” (or you could do surgical nursing) for 13 weeks of lecture only prior to the CC internship as well.

  • GuitarGirlRN

    November 25, 2007 at 8:59 pm

    I’m an ADN graduate. Our program had over 770 clinical hours in the two years I attended, plus required summer externships (six weeks of three eight-hour shifts a week). I was definitely more prepared with technical skills than the other new-grad RNs in my orienting class at my first new RN job. However, other ADN programs don’t have nearly that much, and the BSN students were even more poorly prepared.

    As a first-year student, we were at the bedside two days a week, and had up to three patients each as our skill levels grew. As a second year, we had up to five patients each, were in the hospital three to four days a week, and towards the end of the second semester were responsible for the total care of our patients. The only thing we didn’t do was hang blood transfusions.

    Then, we had a “Pathways to Practice” segment right before we graduated, where we were to work three 12-hour shifts a week for three weeks, and were expected to take on a full caseload of patients (up to six, depending on specialty area). It was a very eye-opening experience for me.

    As an adult learner (I went to nursing school at 32, after two other careers), I found that an ADN program was best for me because it was fast, gave me the ability to work at the bedside right away, I was able to do it all in one fast shot, and now the hospital I work for is paying for my BSN and Masters degrees.

    I think it’s great that you’re thinking of going into nursing education! We need great clinicians in the educational setting. My mother was an RN for over 50 years–20 at the bedside and 30 as an educator. She found teaching to be very rewarding, and I know I’ll probably end up in nursing education eventually!

  • whitecap nurse

    November 25, 2007 at 9:11 pm

    Dear Kim,

    I wear my cap every day (but I still get razzed). Little old ladies really, really like it. All my patients know I’m the nurse (not doc or tech). Try wearing yours sometime!

  • annemiek

    November 26, 2007 at 5:10 am

    I went to a diploma school. Plenty of clinical practice, sure, but not much theory. We were just used as cheap labor, very scary too. As a 2nd year student I was alone in the night shift on a unit.
    I really see the difference in students from the local community college between the ones that did an externship and the ones that didn’t. The externship is optional and there are limited places.
    I just finished orienting a new nurse from that school (no externship), they only get 6 weeks of orientation, and then are supposed to have 5 pt’s for a few weeks. Well, that works as long as the census is down, so the reality is more like 6-7 pt’s. It is a great struggle for the new nurses, there is not enough clinical practice in this college they come from, unless they do the externship.

  • Shannon

    November 26, 2007 at 7:27 am

    I did a BSN program as a second degree student, so I only had to do the nursing program. It took me 2 years and I feel like I had a lot of clinical experience. Now, I also think that you could never have enough practice before you start! I just graduated this past May and started working in an Emergency Room in August. My employer required me to take a 6 week Critical Care course that they taught as part of my preceptorship. The strong base I had in theory and pathophysiology made this course really easy. I feel like I was well prepared with skills, but doing it on the job was the best education in skills that I could have received. I also went to work at a hospital in a totally different state than I went to school in and the equipment and policies and procedures were different, so I had to re-learn things anyway.

    There were 4 people from my university in my Critical Care class and we were heads above the other students. Our confidence in our background knowledge made everything else much less daunting. I have to note that my senior year practicum I worked 6 weeks in an ED and 6 weeks in an ICU. During that time, I took on my preceptors entire load. In the ICU I had her 2 two patients and I did everything. I worked there 2 12 hour or 3 8 hour shifts a week and had class 2 days a week. My program also required us to do 200 additional hours (most did more) of an externship or work as an NA in the summer between our junior and senior year. The great thing about that was that you got paid to practice skills and see how the real nursing world worked. I did mine at the VA hospital and worked my rear-end off!

    I tend to disagree with this whole “BSN students don’t know skills” opinion. I work with new grads from both BSN an ADN programs and when it comes to skills, you can’t tell the difference. In fact, I would say that the BSN grads are more confident in what they do know and that makes a huge difference. I have to say that I am happy with my nursing school program and feel like it more than adequately prepared me to be a new nurse – can I function at the same level as those with experience? Absolutely not and I think this is also a problem with our field – we tend to want to come out of the chute with the skills of someone who has been doing it for a while. You cannot compare yourself to your collegues unless they are also new grads! No matter what your educational experience is and no matter how many clinical hours you have, you will never feel like you are prepared when you first start.

  • Candy

    November 26, 2007 at 8:26 am

    Kim, your cap will do double duty now: it has Green Bay colors!

  • Marijke

    November 26, 2007 at 11:02 am

    I went to a college here in Quebec, it’s not a BScN but it is an RN – don’t know what that equivalent is in the US.

    In our first year (we’re talking 1978 here), we went in to the hospital one “day” per week (I put quotation marks around day because we finished around 2, I think). That was for the first two semesters/first year. Second year, we did two days per week for the two semesters and then, I *think* it was 3 days per week the last year/2 semesters, but it may have been 4 the very last one, I can’t recall.

    I do think we had a good bit of clinical experience, but I don’t think we had enough real-life experience. Caring for maximum three patients doesn’t get you ready for when you’re thrown into a situation with 8 patients.

    And we didnt have caps. No cap.

  • Dawn

    November 26, 2007 at 2:02 pm

    I attended a University BSN program, and felt I had no where near enough clinical time as a student. 1-2 days clinical (plus 4 hours “pre-clinical” where you researched your patient) was not enough. IF you were lucky, you had 2 patients to care for, otherwise, it was 1. Procedures were a rarity; we got to do a lot of baths, a few lucky ones got to do a foley. Very rare to do anything like a dressing or anything like that.

    I was fortunate; a local hospital has a ‘nursing assistant’ program, for senior nursing students (3rd year BSN students, 2nd year diploma school). We did EVERYTHING the nurses did except pass medications and hang IVs. We had 8-15 patients, depending on the floor, did charting, etc. It was great training for the real world. I graduated with classmates who had never cared for more than one person at a time, had never done more than a bedbath, had never done a dressing change, or anything.

    As for caps….I hated my cap. We didn’t have to wear them as students, and I never did except for capping and graduation. First, it required LONG hair to wear properly; you needed a bun and 60 hairpins for the darn thing to stay in place (I’ll just say the school colors are Maize and Blue….) Don’t think I’ve even seen my cap in 20 years now.

  • JohnS

    November 26, 2007 at 2:11 pm

    BSN grad last June here in CA Bay Area; 1st year about 8 hours/week floor time in a SNF for 1 1/2 quarters – maybe 100 hours total.

    2nd year about 10 hours a week for 3 quarters (1 pt per day 2 days/wk), about 300 total; pre-floor preparation time the same or a little more. Sat in on report for the nurse really responsible for my 1 patient, mostly listening for ‘mine’.

    Some people got internships between 2nd and 3rd years, but they were not available to everyone.

    3rd year 240 hours (30 or so full shifts with a preceptor) in 1 quarter, moving from complete newbie on the floor to supervised ‘those 5 patients are MINE’ in 7-8 weeks. Took and gave report every shift. Never inserted a Foley (most pt came from ED and already had them, if needed); 1 IV stick (worked -perfectly-, 1 try. Beginner’s luck!)

    Staff nurses are all over the map in what they will or can let us do; depends on patient load and acuity, of course, and hospital policy. We couldn’t do IV push meds until 3rd year; I was told that was part of the school-host facility contracts. Still could not hang blood products 3rd year, but other 3rd-years could at their hospitals. A couple of time a staff RN grabbed me and said “You’ve never seen this – come help me do X.”

  • Diana

    November 26, 2007 at 4:19 pm

  • Janet

    November 26, 2007 at 8:59 pm

    I think clinical experiences vary widely from program to program and it does not seem to depend on the type of program. Whatever type it is,I don’t think students get enough clinical exposure or time.

    I read somewhere sometime that it takes a new nurse at least a year after graduation to become competent, maybe more. You can’t expect a new grad to perform like an experienced nurse but you can provide more tools than current nursing education seems to be providing. In spite of all the theory, nursing is very task oriented as far as day to day workflow goes. New grads should at least be able to do more than give bedbaths and empty bedpans. I’ve seen too many who have never had the chance to insert NG tubes, start IV’s, do wound care, give meds to more than a couple of patients, perform basic assessments, insert foleys, or even turn and position patients correctly. And in 30 years I have never seen one (including me) who had any training in time management or prioritizing care.

    I vote for increasing clinical hours and internships and developing strong mentoring programs with experienced staff nurses. If more hospitals could find some way to get their staff nurses more involved with training students I think everyone would benefit. I also think students should be more exposed to some of the specialties that are not confined to hospitals such as dialysis, hospice, blood banking, and occupational health to name just a few.

  • Wanderer

    November 27, 2007 at 12:10 am

    If memory serves (I’ still trying to block out the memory of nursing school…) we had about 16 hours a week (2 eight-hour days) through each semester. Couple that with a 120-hour senior preceptorship and a paid internship where I worked full-time for the summer months and holidays, then part-time for he rest for a year, I actually felt pretty comfortable at the bedside. That is I felt good at things like time-management, prioritization and assessment skills. Technical nursing skills (other than monitors – the internship was on a tele floor) like IVs, NGs and Foleys were a little on the lacking side. Lucky for me my senior preceptorship was in the ED so I had a pretty good exposure to those things. As I look at it though, those were the things that weren’t that important. The other things I learned were. Now on the floor, rarely do I start lines, drop NGs or Foleys. Most of our folks come to us with the neccessary tubes. Can I do it when needed? Sure. I think I came away a little lacking in the technical skills part, but better at what I actually did on a day to day basis. When I started on the floor, my preceptors commented to me that I was a lot better prepared than many new grads they had dealt with so I think it worked.

  • miss-elaine-ious

    November 27, 2007 at 2:01 pm

    In Ontario, you have to do a BScN to qualify to write the RN exams.

    I’m in an accelerated program (2 years versus 4), but we get just as much clinic time as the regular BScN students.

    For the 19 months we were in the program, 1 month was spent doing 40hrs/week at long term care, 6 weeks were spent doing 40+ hours a week in an acute care experience, for 3 months we spent 2 days a week in both a mental health or community placement, and for 3 months we spent 2 days a week on labour and delivery, and paediatrics. Finally, we end with a week of 12-hour shifts in an acute care placement before we do a 3 month internship of 450 hours.

    Phew. Just thinking about all the clinic makes me tired. Although we didnt’ get more then 2-3 patients at a time, during the internship we are expected to do a full assignment by the end.

    I have had the opportunity to do most nursing skills.. foley’s, IM and sc injections, hang all meds but chemotherapy, hang blood, do wound care.. etc. The only things we don’t get to do are ‘advanced skills’ needing to be signed off by a doc… drawing blood, starting an IV, and hanging meds through central lines. However, we will get that experience during internship.

    I think that we have had some great experience, and I hope its enough. HOwever, even after all this, we will still be green and wont’ have the “nurse’s instinct”, but I’ll surely start to build on it each time I’m working!

  • Caroline

    November 28, 2007 at 7:51 am

    We do 96 hours for the following:
    Med Surg 1
    Med Surg 2
    Mental Health
    Public Health

    And then something like 118 hours for Senior practicum.

    Total: 694 hours

    Seems like a lot, and I think it’s a good balance. I can’t stay in school forever, ya know!

  • tele nurse

    November 28, 2007 at 9:48 am

    ADN program here. We had to do 1 day a week for the first year, and 2 days a week during the second year. Also included in that time for the first year was the skills lab, so that made it really 2 days a week. Never did get to do a whole lot during the assigned clinicals. It was just luck I suppose. I did get much, much more experience working as an extern while in school. In fact, it made up for all the experience that I didn’t get during that time.

  • Mon

    November 28, 2007 at 8:19 pm

    I certainly feel that I am not yet prepared. i am good in NGT and IV’s (although IV insertion is not allowed here in the Philippines even for untrained RN.. there is a special license for it.. i dunno about there in the US but that’s the way it is here). Sometimes I steal IV stuff and others and we practice the insertion at home.

  • little nursing student

    November 29, 2007 at 7:24 am

    I am a senior in a BSN program. We had clinical one day a week, 8 hours (usually only around 5-6 hours of that actual floor time) for each “area”, long-term care, three med-surg rotations, psych, OB, peds, and community. The quality of our clinical experience largely depended on our instructors. In one clinical, I had an instructor who didn’t allow us to pass meds. He was fired when the administration found out.

    Once a week for a few hours is not NEARLY enough to really let the student nurse begin to evolve into a ‘real’ nurse. Which is why I, like so many others here, applied for a nursing externship. I was extremely lucky to get it, it was a very competitive program. Out of 80 students in my nursing class, only 3 of us got into externship programs that summer. Of course this was not mandatory and had nothing to do with the BSN program. But it was the first ‘real’ experience I ever had as a nurse. 36-40 hours a week for 10 weeks. Once my preceptors felt comfortable with my skills, they set me loose and I finally felt like a ‘real nurse’.

    Finally I had my 100 hour preceptorship as a senior. But they are doing away with this as a result of the difficulty of finding preceptors for the students.

    I definitely think that a little more time on the floor is needed in BSN programs. They are doing their best to improve this at my school, but it’s a slow process, and sometimes impossible to do with staff nurses having less time to take on students and less staff available to teach them as the nursing shortage begins in earnest.

  • Amie

    November 30, 2007 at 7:14 am

    I’m a Junior BSN student and while we get quite a bit of clinical time (12 hours per week for 7 weeks per clinical), what irks me is the fact that we don’t get to actually DO the things we’ll be doing in the field. Case in point: IV push medications. We are not allowed to push anything stronger than friggin Normal Saline through an IV line. Not even a Heparin flush! It’s ridiculous if you ask me.

    Anyways, we rotate through all the major areas: Long-Term Care, three Med/Surg (Medical, surgical, and ICU), two psych (one acute care, one long-term care), OB, Peds, Public Health. I’m not sure how I’ll do once I graduate in 18 months – but as of right now I’m scared shitless to graduate simply because I don’t feel confident in my skills. I have yet to start an IV on a real patient, I have not dropped an NG or a Foley. I can do CNA work pretty good though…since a lot of our clinicals so far has been glorified CNA’s.

  • moira

    December 3, 2007 at 6:56 pm

    I just finished my maternity clinical without ever seeing a woman in labor, a baby born, a circumcision. But I am an expert at pp teaching. boo.

  • tammy

    December 6, 2007 at 1:24 am

    I believe skills and critical thinkings come very individuallly. A BSN is not better than ADN or vice versa. I do strongly believe if any nursing student can find a hospital that hire extern, that is the best way to ease his or her way into the transition between class and clinical setting. I wish there’s internship for nursing just the the MDs and teachers(at CA) does.

  • Yvonne

    December 7, 2007 at 1:07 am

    Kim, I graduated with my ASN from Regents College in 2006 and have worked in the ED since graduation.I worried that my skills and abilities would be lacking since I did not have the traditional school experience.It has turned out not to be problematic at all. I was an LPN for 15 years prior and I lived,breathed and bathed direct patient interaction in that capacity.Getting mt RN through Regents was not the “easy ” way and took much determination and self discipline to accomplish and those qualities have served me well in my postion. Sometimes A totally new concept will be presented that makes me think”Oh should I know that?” But then noone knows everything. As an aside when I worked the floors we would have RN and LPN student nurses on rotation at the same time and the RN students were always watched much closer as they seemed to be theory heavy and common sense light.

  • […] that could bring the total up to almost 1000 clinical hours for this program. Not bad considering the amount of clinical time in spent in nursing school is definitely a controversial […]

  • […] over at Emergiblog has been talking about clinical vs. theoretical experience. She put out a call for opinions on the subject. Disappearing John RN has already put in […]

  • tammyp

    December 18, 2007 at 7:18 am

    I’m not sure if the type of program is as important as the type of person. We all know nurses with more letters behind their names than common sense and I think that’s the basis of all good nurses…common sense. That and a decent work ethic. When I graduated from my diploma program in 1982 nurses had the attitude of “what can I do for my work”. Now I see a lot of new nurses who ask “what can my work do for me”.

  • bunny leong

    January 16, 2008 at 2:29 am

    i’m donna a student, i realized that being a nurse is not just a course and a job.. you will never be a good nurse if you don’t love your profession because the work of a nurse is not easy.. when you decided to be a nurse then you have to keep your foot on the ground.. though i understand and realized still its hard…

  • Confuess

    April 25, 2008 at 12:12 am

    ok, I have started nursing school but drop out because of not making much and in school, however plan to work and safe some money so
    I go back full time. Yet; I like to work alone with a surgery as a tech, need more inform on being a surgical tech please. Any adivce

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

Continue reading »

Find Me On...
Twitter     Technorati

Subscribe to Emergiblog

Office of the National Nurse

Zippy Was Here

Healthcare Blogger Code of Ethics

  • Perspective
  • Confidentiality
  • Disclosure
  • Reliability
  • Courtesy