Guiding Novice Nurses (With Dr. Lisa Nicholas)

It's no secret nursing school can be tough, but how do new nurses overcome their anxiety? UNLV Nursing Professor Dr. Lisa Nicholas explains common stress triggers for nursing students; why there is a thing as too much confidence; and what instructors and hospitals can do to foster positive learning environments. Recorded 8/2/2022

Joe Gaccione 0:04
Hello and welcome to Vital Views, podcast for UNLV School of Nursing. I'm Joe Gaccione, Communications Director for the School of Nursing. One of the most fundamental objectives of a nursing school is bridging the gap between school and the real world. Undergraduate nursing students go through intense, but manageable, semesters before they take their licensure exam to officially become registered nurses. As students progress, each semester becomes more critical for their clinical and personal growth. So, these new nurses are not just technically proficient, but confident in what they're doing. And talking about novice nursing students and what they go through, we are pleased to have Lisa Nicholas here with us. She's a lecturer at UNLV School of Nursing. She also just took up a new leadership position as the faculty coordinator for the Clinical SIM Center of Las Vegas. Most importantly, she's kind of an expert on this subject. She just successfully defended her dissertation on building confidence in new nursing students. Lisa, thanks for stopping in.

Lisa Nicholas 0:55
Thanks Joe, for having me.

Joe Gaccione 0:57
Well, let's start with that dissertation. Where did you get started on this topic?

Lisa Nicholas 1:00
It started from the student population that I primarily work with, our level one nursing students.

Joe Gaccione 1:06
And what did you find? Like what, what did you research specifically?

Lisa Nicholas 1:09
I noticed that students are scared, and they're scared, look, they're scared-looking, and they're scared. And from day one, we really impress major safety. Safety, safety, safety, and the implications of safety in practice. And so, from that perspective, the students become more fearful of what they're going to experience in the hospital, what they're going to see, smell, and do for patients, and they really don't want to do anything that's going to hurt anybody. But then that also creates barriers for their learning. And so, that was the impetus of my dissertation.

Joe Gaccione 1:48
When we talk about new students and what they're trying to do or not do, that anxiety, you just mentioned it, that they're not just feeling it, but they look it too. So, is it that easy to pinpoint when a student is frozen, so to speak?

Lisa Nicholas 2:02
it is, 100%, because they're not able to translate anything they've learned into clinical practice. So, you don't have that transfer of knowledge into what they're supposed to be doing for their patient in terms of patient care.

Joe Gaccione 2:19
How do you break them out of the cycle? Is it easier said than done to say, “Hey, it's gonna be okay,” or does it require more direct work?

Lisa Nicholas 2:27
A little bit of both, it depends on the student. Our students are incredibly accomplished and intelligent and they have to be to get into our school because it's very competitive. But once they come into the school of nursing, everything they've done up until this point in their academic career, we kind of say, “Well, great, but now nursing school is going to look a lot different. The grades you're gonna get are going to be different, the work you have to put in is going to be different, how you study is going to be different.” Once students get the hang of that they're able to kind of use that anxiety for good, it helps keep them awake and alert in knowing what's going on, but then you have a small population of students that it really impedes their ability to be successful.

Joe Gaccione 3:14
That's a great point. You can use stress for positive things, it's good to have stress, it's good to have a little anxiety, it keeps, you know, your foot on the pedal to keep going and also to be aware, “Okay, I can't just coast through this,” especially in a health-related profession. So, it's almost like trying to balance it out, like you can have some but not too much because then you don't want to be overconfident either.

Lisa Nicholas 3:35
Correct, because either way, you have an incredible lack of confidence or overly confident, both are not safe and they won't do you any good in your nursing academic career or your nursing career because it'll have major implications on the patient safety.

Joe Gaccione 3:53
Now, having the SIM Center, specifically the one here in Las Vegas, having that there to teach students you can, basically practicing on manikins, practicing on each other in a safe environment where if they make a mistake, they're not actually hurting anybody. So, there is that level of feeling, “It's okay, this is why I'm, this is why we're here, is to learn at this stage, so we don't make the mistakes later on.” But even in simulation, there can be barriers, correct?

Lisa Nicholas 4:20
Correct. The student confidence, lack of confidence in their anxiety still impedes their learning at the SIM Center. The simulation center is really incredible because it harnesses this low stakes, safe environment where they can make any sort of error and it's non-punitive. Like, it's not, you're not gonna be held back or held accountable to learning experience. Most students do really well in that sort of environment. Lots of hands-on repetitive practice. But again, it's that small population of students that they just can't seem to get a handle of, “I'm learning this because, I'm going to use this because, and then I have to remember everything I've learned, plus the hands-on component of it to transfer into real practice.” And those are the students that we really tried to find and focus in on, as the level one faculty, to support them more. Trying to eliminate any learning barriers they have, working more one to one with them, and just providing them more guidance and support so that they can get over, I guess, whatever barrier they have and are a little bit more successful. And some students just need a little bit more time to mature and grow and become competent. We can't say, “Okay, well, you have 15 weeks to be safe and competent. Good luck.” Some students need a little bit more time. So, I think it's really our role in level one to give students more time, give them a different perspective, if they need a little bit of our perspective or a little different approach, to facilitating their learning, and the Simulation Center is one of those really fantastic resources that we utilize to do that for all of our students, in whatever capacity they need.

Joe Gaccione 6:14
And the simulation center, if you haven't been, it's, I mean, it is what the name says. It simulates hospital rooms, labor and delivery rooms, emergency rooms, and we say manikins, but these are lifelike manikins, they will talk, they will show blue if they can't breathe. I mean, you can use them for so many different things and from stories I've heard, it still can get emotional, even though they're not real people. When the students make a mistake, yes, there is that comfort of knowing they didn't actually hurt somebody, but it can get intense because oftentimes students will feel like they did hurt somebody and it does take an emotional toll on them.

Lisa Nicholas 6:49
Exactly. They take the actual high-fidelity simulation experiences very seriously and very personally and they stretch a good expanse in experiences across the program from just basic interactions with patients communication, acknowledging abnormal vital signs, we talk about end of life care, even psych simulation experiences. And the students walk in with objectives. They understand what they need to complete in this scenario because we talk about it before, but the students lose that plan very quickly, when it becomes more real life. And so, then that causes them to really pull from the knowledge they have in their brain and put it to use. “What have I learned about this? What do I know about this? What can I do about this?” Sometimes it goes great and sometimes it doesn't and we anticipate that, so we don't let the student hang out in these simulation scenarios failing for, you know, long periods of time. If the students aren't meeting the objectives, we pull them pretty quickly, because then the learning experience can take place in what we call debrief, where we sit around and we talk about what went well, what didn't go well, and what are opportunities for improvement, but it's never a, “Wow, that was truly terrible. You're gonna be a horrible nurse.” You know, it's always, “Okay. It didn't go so well, why, and how can we make it better next time?”

Joe Gaccione 8:24
Your topic, this topic, reminds me of a somewhat similar one one of our alums did. Her name is Wendy Matthews, she teaches out of California, and she looked at Generation Z emotional processing. And she was noticing something similar, how her students would freeze. They were so anxious, they couldn't perform. And there were different ways that she would try and work with them, you know, be more empathetic, have those debriefs, making sure that was a necessity not just something you should do, but you need to do. But one thing she talked about, that made me think about like, a generational aspect, do you feel like more new nursing students, they’re just, automatically have that built-in pressure compared to maybe previous generations? Is that something you've noticed?
Lisa Nicholas 9:07
That's a great question. I think every generation has a different approach of how they cope and how they were taught to cope. And that's one thing that I've noticed a lot in this newer generation is that there's a largely used label of anxiety. Now, I'm not a clinician that diagnoses, so I can't say that they have legitimate anxiety or not, but when everybody comes in and they have some form of an anxiety, that really worries me, because how is that going to help you in your academic career if you continually, continually are acknowledging this problem that you have? Okay, you have anxiety, let's acknowledge that, but ultimately, how are you going to get through your anxious moments? How are you going to cope with it and how are you gonna be successful? And that's what I've noticed about this particular generation of learner is how they deal with stressful situations. They don't really, it impacts their entire learning ability, their academic life.

Joe Gaccione 10:13
One aspect about this generation that I talked to Wendy about is that newer generations, you know, they have more technology at their disposal. They can research more things on their own, but they also see more, and not to sound like an old fuddy duddy, but you have social media out there. And it can, it can go both ways. And that was something that Wendy had brought up too, was that you, people can use it almost like a stress reliever, like, “This is what I do to unwind,” but then you also, if you see other people being successful, like if you're seeing other students, your friends, they're rocking it and they're posting stuff, it's going to make you feel like, “Well, how come I can't get this? Is there something wrong with me?” It's fascinating to see like, you can, it can go either way. Like, it can be positive, but it can also can be rough.

Lisa Nicholas 10:51
It can be really rough. So, with my dissertation and my study, what I wanted to do was level the playing field and set all of the students up for success equally, utilizing the simulation center, and allowing the students to learn all of their skills, within their scope of practice, and all of the assessments, techniques that they'll need to assess a patient before going into this high stakes environment of real clinical practice. Would that help the students feel a little bit more confident and a little less anxious, knowing that they have a toolbox that's filled with useful things? I was surprised to find out that in comparison to the two groups of population, the one group that went in with all of the skills and assessment and didn't start clinical till after they had learned all of it was just as anxious and lacked confidence just as much as the group that was in clinical early on, and they were learning skills and assessments as they went. So, it then became, you know, “Well, what's next?” because it's not really about the timing of learning things. The playing field was the same really, for everybody, it was just the timing of it and that really wasn't a factor for the students. So, there has to be something else that's really causing a major barrier, creating this high anxiety sort of situation. It could just be the nature of nursing school, I can certainly say that from my, from my own experience is that I was a major stress ball, major. And it wasn't until I became a nurse and actually interacted with students that I was able to like, I was empathetic to them and I could understand now why they were so afraid to do anything in clinical. “I'm patient with them, I'm a nurse, I'm like, “Come on, let's go take care of my patients for the day. Let's have a great day.” You know, I was kind to them, I was patient with them, but they were still terrified. And the question is “Why?” I haven't figured that out yet.

Joe Gaccione 12:50
There's so many aspects of when you're a new student, and you're trying to put it all together, especially that first year. And it's not just the academics, you're still in college, you're still trying to figure things out. Now, you have this whole new routine, now, you're trying to figure out time management, and you don't know what you don't know, you don't know that, it feels like it's just task oriented right now, but there's a process. You talked about before, like, not just understanding what you're doing, but why you're doing it. Is there anything, any particular advice you give them as far as maybe like personal time, like, “Hey, don't neglect that because that could build up too,” because if you feel like you don't have that time, and it's all just school, school, school, you're going to be anxious all the time?

Lisa Nicholas 13:27
Absolutely. I tell the students that every semester and I check in with them often, to ensure that. The schedule is really important, time management, organization are crucial in nursing school and that's going to teach them and set them up for success as a practicing nurse. So, they have to start it early. In that schedule, in that organization, time management, you got to schedule personal time, and they need it. You need some downtime to be with your family, go and exercise, go on a hike, do some yoga, whatever it is that you desire to do, make sure you schedule it, and you can't forget about yourself because we're really impressing health promotion and wellness to our patients, except we're ignoring it for ourselves. That doesn't really make any sense.

Joe Gaccione 14:11
It's always easier to tell someone, “This is how you relax,” but if you're not practicing yourself, it's like you still have to take time for yourself. We mentioned before, new role at the SIM Center, faculty coordinator. Can you tell, I know it's only a couple, you're only few days in, but can you talk about this role and if this will augment your efforts to support those new students?

Lisa Nicholas 14:29
My goal in this new position at the SIM Center is really just to harness an environment that will create a culture of belonging. It will harness a culture of success, a community because that's really what we are. We are the School of Nursing and yes, you have levels one, two, three, and four, but we're a community. All of the nursing students are going through the same thing, just it looks a little bit different. So, I think the SIM Center is a really great place to, that brings everybody together. allows them to learn in a safe learning environment. And so, I really want to continue to keep that going, that perspective going at the SIM Center and really try to make it a place where faculty voice is heard about really great innovative, new teaching and learning pedagogies and that can be then facilitated for the students.

Joe Gaccione 15:23
Putting that culture together I think is incredibly underrated, even though we hear about it all the time, it's so easy to miss, but the I think the long-term impacts are so devastating if handled improperly. And that's one of the things we talk about. Nurses, new nurses, they’re finally out in the real world, but there's, the environment’s not what they maybe thought, it's not positive, it's not conducive to them and that leads to burnout. Are there still things that we can do, not just necessarily UNLV, but just in general, in nursing schools to minimize that gap between final semester and first year as an RN?

Lisa Nicholas 15:56
I think we need to focus more on the School of Nursing’s ability to help the students with this transfer of learning. So, taking your knowledge, your classroom knowledge and your practical skills, and being able to apply it in a real-world situation. From employers, and just having conversations with nurses on the unit or being a nurse myself, I've witnessed and I've heard that new graduate students don't really have that skill down, like they're not able to do that transfer. And so, as much as nursing school is this huge learning curve, so is being a new graduate nurse. And so, there are things out there to try to mitigate that, you know, there's new RN graduate programs like residencies, but I think certainly the culture of the unit really has a lot to do with helping these new graduates kind of overcome this transitional period. If you have a workplace environment that really, is really glad that you're there, they really feel, you know, happy to help you grow professionally and personally, there's a manager, down to the charge nurses, down to all of the nurses that work on the unit that are there to support you in this, that graduate nurse is going to feel much better about what they're doing and the fact that they're learning and everybody knows they're learning, but are supportive of their learning, I think that's going to take away the sense of you know, “I'm, I really shouldn't be here, I'm not ready for practice,” or “That nurse was kind of mean to me,” or, you know, “I made this error and they're really throwing it back in my face.” I can see why some graduate nurses really are like, “This is a bummer, nursing is not what I thought it would be.” A lot of it has to do with the work culture.

Joe Gaccione 17:35
My last question for you, as an educator, is there one moment you can recall when you knew you reignited that fire in a student, when you knew they were anxious, and you unlocked something, and all of a sudden, boom, now their confidence was back up, and they started performing better?

Lisa Nicholas 17:51
Yeah, I would say I have a lot of, I have a lot of those moments, but my most memorable one, and I don't want to, I'm not trying to brag or boast, so I'm going to come back to why I have a lot of those moments. But my first one was as a bedside nurse, and I taught, or I worked at a teaching hospital, so we had students on a continual basis for five days a week. And I actually, before I worked for UNLV, had a UNLV student who was very timid and afraid. And it was that student that as much as I was kind and patient to them, they were just like, it was so hard for them to do anything that day until we had a conversation. And they were just so terrified of making a mistake, because they made one mistake already and instead of turning it into a learning experience, I guess the instructor, or from the student’s perspective, it made them feel really bad, maybe you should be thinking about being a nurse. And once I had the conversation, and I understood where the student was coming from, just for that student to be heard, they felt much better about what they're trying to accomplish. So, I was like, “Look, I am not perfect, I've made a med error. I, you know, forgot to give a patient a medication.” Like, I tried to give a couple of examples of how even being a nurse with a license, I was not perfect, so, and what you're trying to accomplish in getting your license is to be out there and take care of people and have an ethical responsibility and accountability for your patients. And so, that really was the moment that that student was like, “You know what, I appreciate you so much. Thank you. Thank you for explaining everything to me so clearly and your patience.” And that moment, that interaction was like “Okay, I, I want to teach. I like you. I like the way you made me feel, you like the way I made you feel, I liked our interaction. I want to do that more.” And so, that was kind of the defining moment of when I decided to go back to school. For my Master's in Education.

Joe Gaccione 19:49
There's something, it's so small, it could just be a few minutes, one on one time, that can make a difference. And just as it could take a few minutes to really bring someone down, you can use that time and do the opposite and lift them up. Yes, in a moment, and depending on the severity of the situation, you can have heightened feelings at that moment, especially if you're an instructor, but if you don't take advantage of those teaching moments, you lose an opportunity.

Lisa Nicholas 20:12
And that’s what, I say that I get positive responses a lot is because I check in with the students often. There are 72 of them, there's a lot of them, but you know, what am I teaching for? You know, just to like, “Okay, these are vital signs. This is why we wash our hands.” I want to get to know these people, I want to make sure that they're good people, that they have the support they need, that they're going to be supported in their learning. So, for the 15 weeks they're with me, I can 100% say that I tried to reach out to all of them, at one point or another, to make sure that I know the person, that I say, “Hey, how was your mom's birthday? Oh, hey, how's your son doing? I heard, you told me he was sick. How's he feeling now?” And so, getting to know them as a person, not as just a student, really helps them to at least understand, I guess that sense of community that, we're all, “We're all in this together,” it's from High School Musical, just so everybody knows. But we are, we're all in this together. And when you graduate, as a nurse, I want you to be a good nurse, I want you to be a caring nurse, not that you're not going to be if we don't have these special moments, but getting to know the person is crucial, just as we get to know our patients.

Joe Gaccione 21:29
Well, that is all I have. Lisa, thank you very much for joining us.

Lisa Nicholas 21:32
Thank you. I appreciate you.

Joe Gaccione 21:34
Congrats again on the defense of your dissertation and good luck in the new role.

Lisa Nicholas 21:39
Thank you so much, Joe.

Joe Gaccione 21:40
Thanks for listening out there. Have a great day.

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Creators and Guests

Lisa Nicholas
Lisa Nicholas
Professor, UNLV School of Nursing
Guiding Novice Nurses (With Dr. Lisa Nicholas)
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