Nursing Student From Hell

[DWelly14]

So I need help. I've been a nurse for 6 years now. I have a BSN & an MSN and am also a CNM. I've worked 4 years in critical care and the past two years in labor and deliver at a large suburban hospital. I've precepted several students and have always had positive experiences with them. I was not planning on taking another student this semester as I finally am transitioning into full scope midwifery practice but the local nursing school was desperate so they talked me into taking one last student. So in January, this student, let's call her Alice, started with me. When Alice first started she seemed very unsure of herself. She's a student though so not unexpected, even though this is her last rotation before graduation. But I got my teach on. We discussed anatomy and physiology of pregnancy and labor, walked through procedures at least 10 times, I stayed after every single shift to work with her, and she always went home with printed out policies and articles to read up on so we could discuss on our next shift. I felt like I was seeing improvement but I was always right there with her helping with her during the first 6 weeks of her rotation. When we had her midterm evaluation with her faculty member, Alice was told she was to take the primary role and I was to back off. So that's what I've been doing. Unless safety is in jeopardy, I've kept my hands off. And Alice is crashing and burning. To the point where I'm not sure how she's made it this far in her program. She is lazy, refuses to do basic nursing tasks such as starting IVs, and will just go hide to get out of things. We admit a patient. I go in to the room with Alice, she just stands there. I say "Ok, go ahead and get started." She says (in front of the patient mind you) "well, I haven't done many IVs so why don't I watch you one more time?" I say " you only have 2 weeks left, you only have so many chances left ... " Patient chimes in "I want you to start my IV please DWelly14!" .... opportunity lost. Fast forward to when the patient is complete. Alice is nowhere to be found. I'm in pushing with her and the charge nurse has to find her. Several of my coworkers have commented on her behavior to me, I've confronted her on it and she always makes excuses, and I've now emailed her faculty.

My question to all of you is do you have any tips for what to do? I feel bad just recommending that she not pass but at this point she only has 3-4 shifts left with me and I'm getting really frustrated with her. I'm really not willing to take her for any longer than the originally assigned amount of time because of the behavior I've observed. I feel like she's skated by through her whole program somehow and now she's finally having to actually do it and she can't. Help!

[Meriwhen, ASN, BSN, MSN, RN]

All I can say is I WISH I had been able to start an IV during my practicum. I got to do a lot of other things, but my school didn't allow IV starts (nor teach it) and the nurses on that floor didn't do IV starts either, they called the IV team. And OP, you sound like a great preceptor!

I was allowed to do IV starts...the problem is that the opportunity never presented itself, nor did my preceptorship preceptor even bother to find one. I think my preceptor was just happy to have the free labor so they could take it easy. Everyone but I in the class got to start, or at least attempt to start, an IV.

I was the only in my class to get to do IMs though. Whether that was yet another omen that I was to become a psych nurse (the very first omen was drawing restraints as the skill to demonstrate in Fundamentals, and it progressed from there), who knows?

Anyhow...I would have loved to have a preceptor like the OP. Alice truly has no idea what a great opportunity she threw away. Because there's no guarantee the next preceptor Alice has will be willing to go that extra mile for her...especially if Alice's reputation precedes her.

[Lola Lou, BSN]

For the sake of this student's future coworkers...fail her! The last thing a nursing unit needs is another coworker who constantly dodges her respnsibilities. This type of coworker leaves the rest of the nurses on the unit to pick up for her slack and worry about her patients when they are already overloaded with their own patient responsibilities. I speak from a place where my very first new employee orientee was similar to the student that you described. With my suggestion the unit manager "let her resign" after orientation. She clearly slipped through the cracks during nursing school and my facility wasted almost a lot of money extending her orientation time and time again. I wasted so much time, energy, and feelings of guilt worrying that I could have done something differently. Hard decisions like this made early in a nurses career avoid a lot of painful, tedious, paperwork filled decisions that will need to be made later on. As the nurses chosen to educate and develop new nurses in to competent providers it is also our responsibility to ensure that the integrity of the profession is upheld. You are not in an easy position. If you can sleep at night knowing that you have honestly tried everything to help this student succeed then you already know your answer. Good luck OP!

[2mint]

Mar 10:

...I've been a nurse for 6 yrs...BSN...MSN...also a CNM...4 yrs in CC...the past two in L&D...I've precepted several students...I was not planning on taking another student...as I finally am transitioning into full scope midwifery practice...So in January, this student, let's call her Alice, started with me.”

-OP, given that Alice was likely your 3rd or 4th preceptee, I and a few other saw immediately to question your communication skills and leadership abilities. I'll elaborate as I go.

"When Alice first started she seemed very unsure of herself...But I got my teach on...I felt like I was seeing improvement but I was always right there with her helping with her during the first 6 weeks of her rotation.”

-Good observation and efforts on your part.

When we had her midterm eval, Alice was told she was to take the primary role [VS, IVs, foleys, reposition, meds, H2T as we found out in Mar 14 post] and I was to back off...Unless safety is in jeopardy. And Alice is crashing and burning...She is lazy, refuses to do basic nursing tasks such as starting IVs, and will just go hide to get out of things.”

-Communication/Leadership: Wk1 thru Wk 6 she was "improving"--what is less than "lazy"? Moving on...on day 1 solo, did you re-iterate the expectations of her? See next comment.

We admit a patient. I go in to the room with Alice, she just stands there. I say "Ok, go ahead and get started." She says (in front of the patient mind you) "well, I haven't done many IVs so why don't I watch you one more time?"

-On day 1 solo, you lose nothing by re-running through the process for her, as in, first lets do H2T assessment, then we start IVs, etc. especially when she voices her poor IV skills to you in front of the patient (imagine her embarrassment, that's why she said this 'Alice tried to blame me for not making her feel welcome and for "pushing her too hard."')

Fast forward to when the patient is complete. Alice is nowhere to be found. I'm in pushing with her and the charge nurse has to find her.”

-At this point, you were rightly frustrated, but how is it that she left the room without you knowing? That's a major disrespect which likely stems from lack of communication and leadership abilities...on your part. (Please refer to my first comment above).

I've confronted her on it and she always makes excuses, and I've now emailed her faculty.”

-You confronted her multiple times? Did you once sit down with her to discuss she might be on track of failing this portion of her program? She makes excuses because throughout this 7-week relationship, she simply doesn't respect you (it takes two to tango).

...she only has 3-4 shifts left with me and I'm getting really frustrated with her...of the behavior I've observed. I feel like she's skated by through her whole program somehow and now she's finally having to actually do it and she can't.”

-Those who lack good communication skills do experience more stress in life in general. Your resentment of her ("she's skated") likely manifested in your speech and body language => instant or further disrespect of you.

TL;DR: OP, you had "easy" first 2 or 3 preceptees, now you got a "harder" preceptee and d/t your lack of experience you did not know how to interact with her, ultimately leading to neither respecting either.

I'm boarding in MS, going to ER training soon, so I'm big with communication skills and leadership abilities.

No matter how you define leadership, the main focus of a leader is to get the most out of his/her people. And the first step is to get to know your people.

[DWelly14]

-OP, given that Alice was likely your 3rd or 4th preceptee, I and a few other saw immediately to question your communication skills and leadership abilities. I'll elaborate as I go.

Not sure why you immediately question my leadership skills but ok ...

-Good observation and efforts on your part.

The point was that in the first half of her rotation I was right there with her holding her hand and watching her. Alice is by no means ignorant or incapable, in fact, she is quite capable. She has a bad attitude and is lazy. That's the issue I tried to get at later ....

-Communication/Leadership: Wk1 thru Wk 6 she was "improving"--what is less than "lazy"? Moving on...on day 1 solo, did you re-iterate the expectations of her? See next comment.

Alice started out with the stereotypical student big eyed terror look when you hit the floor for the first time without your nursing school buddies. The first time we walked into a patient room she could barely speak let alone do an assessment or anything else. So I taught her to deal with that. And I taught her the work flow on my unit, how to do an admit, how to prioritize, how to do a targeted assessment, how to interpret a fetal monitoring strip, how to place the fetal monitors, how to start and IV. So by midterm, she had calmed down, she could talk to the patients. She was still nervous and had a bit of an attitude but I thought it was still nerves. That's the improvements I saw. Every single shift when we were walking from the locker room where we met to the nursing station where we received our assignment we reviewed what the expectations for the shift were. Was it an observation day? Was she to be primary with me as a resource? At no time should she have had any question in her mind what her role was in relation to me.

-On day 1 solo, you lose nothing by re-running through the process for her, as in, first lets do H2T assessment, then we start IVs, etc. especially when she voices her poor IV skills to you in front of the patient (imagine her embarrassment, that's why she said this 'Alice tried to blame me for not making her feel welcome and for "pushing her too hard."')

This was not her first day solo. We don't always start IVs, sometimes they come from triage with them already in place, sometimes we come in to a patient who has been admitted by another nurse, it was one example I was using of her refusing to take advantage of a learning opportunity. On her rubric it clearly states that if the opportunity is available to practice skills such as IVs, did the student take advantage of it? At that specific point she had maybe 6 shifts left and she had yet to independently start an IV. I wanted to see if she would even try, as I didn't know I felt another chance would even happen. I'm sorry I wasn't clear enough for you. Perhaps you're right that my communication on an online chat board wasn't clear enough.

Fast forward to when the patient is complete. Alice is nowhere to be found. I'm in pushing with her and the charge nurse has to find her.”

-At this point, you were rightly frustrated, but how is it that she left the room without you knowing? That's a major disrespect which likely stems from lack of communication and leadership abilities...on your part. (Please refer to my first comment above).

We don't stay in the room with the patient, we watch tones from the desk at times. She had many opportunities to wander away, as admit to pushing specifically for this patient and for many patients is often hours apart. And my first priority is my patient. Even my students that have functioned well left the room to run and grabbed needed supplies and didn't feel the need to inform me every time.

I've confronted her on it and she always makes excuses, and I've now emailed her faculty.”

-You confronted her multiple times? Did you once sit down with her to discuss she might be on track of failing this portion of her program? She makes excuses because throughout this 7-week relationship, she simply doesn't respect you (it takes two to tango).

YES!!!!!!! It didn't always start with confrontation. We had many discussions which eventually led to confrontations,if I was going to detail the entire interaction from start to finish no one was going to read it. It would have been too long. I was hitting the highlights.

...she only has 3-4 shifts left with me and I'm getting really frustrated with her...of the behavior I've observed. I feel like she's skated by through her whole program somehow and now she's finally having to actually do it and she can't.”

-Those who lack good communication skills do experience more stress in life in general. Your resentment of her ("she's skated") likely manifested in your speech and body language => instant or further disrespect of you.

TL;DR: OP, you had "easy" first 2 or 3 preceptees, now you got a "harder" preceptee and d/t your lack of experience you did not know how to interact with her, ultimately leading to neither respecting either.

I'm boarding in MS, going to ER training soon, so I'm big with communication skills and leadership abilities.

No matter how you define leadership, the main focus of a leader is to get the most out of his/her people. And the first step is to get to know your people

so I'm curious, would you work with her? Based on everything I've seen from Alice, she's going to continue to do this until someone makes her stop or she's made to leave the field of nursing. I for one would not feel comfortable being her coworker because I'd feel responsible for her patients and mine because I'd wonder if she was paying attention to them or even on the floor. The words "patient abandonment" ran through my head a lot with her because literally if I was not directly supervising even the most basic task (read taking a temperature) she was gone. Even if I have the worst communication and leadership skills on the face of the planet, you cannot place 100% of the failure at my feet and I still can't see how you think you can deduced all these terrible shortcomings of mine from my post.

[2mint]

Thanks for replying and being adult about it—instant respect from me.

I questioned your leadership skills based on the totality of what you said in your original post: did you get anything useful out of Alice? Your original post suggests no. (Leaders do not consider people's doubts about their leadership abilities as a negative).

Regarding my deductions, I'll show you my process:

1) T/F: Alice is your 3rd of 4th preceptee?

Deduction: 2 yrs in L&D, likely started precepting in Yr #2.

Based on your latest post, I was right, you had a few easy, self-directed preceptees early on, then got a difficult one and did not seek advice until 4 days before failing her.

2) CC and L&D are essentially solo practice areas where you don't have to direct other nurses and NA's as often as in the ER or even in MS.

Deduction: self-explanatory (in context of frequency of leadership/comm skills usage)

3) You never sat down with her to inform of her progress. (On your latest post you said you talked to her but led to confrontations instead.)

Deduction: you mentioned about the charge has to find her which came across as in passing and not in a sit-down-post-conference manner (leaders are not passive-aggressive...)

Let me script it for you:

You: "Alice, let's have a talk. You've been here for X shifts, and I see you've made improvements, but at this rate, I believe you are failing this practicum. How do you think about that?"

The difference? My script opens to clarifications/suggestions; if it led to confrontations, then I would stop it asap with relevant fact, such as, did you or did you not refuse to start the IV?” When it comes time for VS, you didn't take them”, etc.

Would I work with her based solely on your descriptions of her?

I believe thoughtful thinkers do not make decision based on incomplete information.

Good qualities: Alice is by no means ignorant or incapable, in fact, she is quite capable.”

She has observed all of this for the first half of her clinical with some guided participation and voiced confidence in each portion before she was asked to do it independently.”

Poor qualities: She has a bad attitude and is lazy” (won't attempt IV's, not taking VS, making excuses, go hide to get out of things”

It's too late now, but it would have been nice for you to start the above script x2 in wk 7 and wk 8, then email the instructor.

Overall, this is an unfortunate case of a difficult preceptee being paired with an inexperienced preceptor (in regards to dealing with difficult preceptees).

p.s.

You did paint a cuddly picture of the first 6 weeks, then a train wreck started in week 7. Too little too late to right the train.

p.s.s.

You are making too big of a deal out of that IV opportunity being lost (and if her IV skills are that bad, not attempting is not as bad as you think)—other thoughtful posters already hinted this to you.

(To put into perspective, I started 3 IV's during clinical; at the end of my MS orientation, I was the go-to for hard sticks

[LadysSolo]

2mint, ADN, RN, the OP did state that she contacted the instructor, the instructor was the one who said that "Alice" was to be"lead" with the OP as back-up. I will reiterate again, as a nursing instructor for the last 10 years, ALL of my students in their preceptorship/capstone (whatever the program calls it) are expected to seek out all the experiences the law allows them to have, as this is their last/best chance to get experience with maximum back-up. The students go in being totally aware of this, and any of mine who would have acted like this person would have failed and had to repeat their preceptorship. I want capable students coming out of our program that are sought as new hires in this area, and I AM proud of my former students I see working when I am doing my other job as an NP. Do I expect a lot of them - YES! But so does the job (when they get one.) I do NOT want them coming out of the program thinking hiding and putting their work off on others is the way to do things (although had one of mine acted like this earlier in the program as I suspect "Alice" has, she would not have made it this far.) I "hunt down" my students if they are not readily visible.

[2mint]

2mint, ADN, RN, the OP did state that she contacted the instructor, the instructor was the one who said that "Alice" was to be"lead" with the OP as back-up...

Why are you replying to me with something that I did not say?

Please copy and paste that specific quote of mine.

(You don't have to; I prefer you not to; you got a free get-out-of-jail card ).

[Extra Pickles]

OP, it's clear you are a caring and concerned preceptor and didn't take your role in this lightly. You gave that young woman every opportunity to achieve, and honestly I think far more than many others would have. You attempted to share your gift for nursing with someone who simply wasn't up to the task. Kudos to you for trying!

[DWelly14]

I did have discussions with her along those lines throughout and the faculty was being kept up to date about what was going on. I feel like you keep choosing not to see this because it doesn't support your theory.

Not sure why you consider me an inexperienced preceptor, just because I have a tough preceptee now. Do you become an inexperienced nurse again when you have a tough patient?

You've made a lot of assumptions about me and this clinical rotation, that up to now I just saw let go but let's set things straight. The rotation is not a set amount of weeks but based on hours so you keep saying week 6 or 7 .... they had winter break which made things a little weirder. You also say I've had 3 or 4 students before, also wrong. Also when I worked critical care, I was the leader of a team of LPNs, NAs, and RTs .... lots of delegating, lots of leadership, and I was very good at it.

You refuse to answer my question about whether you'd work with Alice because you don't have all the info but you've made huge judgements about me with very little information about me. I don't want to say I did everything right in this situation but I will not take the full blame for Alice's failings because at this point she was at in her clinical, she was getting ready to be an independent nurse. She could have secured herself a job on my floor by putting some effort in. Nursing is a very self motivated and self led profession not matter what specialty you are in so if she can only preform when she is being watched, that's a problem. That's not going to fly in the non-student world. My goal for all my students is to set them up for a successful transition into their first job no matter where that is, by showing them skills that can be translated into any specialty, time management, priorotization, communication, efficiency, etc.

Contrary to what it seems you believe my goal is to build their confidence in themselves, I get to know them, let them get to know me, in fact Alice was one of the first to know about my new job. I did not start off resenting her. That came when she kept disappearing, refusing to do things, refusing to try, arguing with attending, arguing with patients. At some point my patience ran out, which is when I turned here, to sound my frustration.

and since we're giving each other communication tips, it's always good to tell someone what they are doing well. Maybe you should have added something positive about me not just about Alice in your comments and then maybe I would t have been so defensive. Thank 2mint, ADN, RN, but Alice has moved on and I'm done precepting until I'm experienced enough to precept midwife students ... it's time for you to move on too.

[Wuzzie]

Dwelly, no need to defend yourself.

[Nurse SMS, MSN, RN]

For all of you suggesting she wasn't interested in L&D, you are incorrect. She chose L&D and wanted to be hired on our floor after this rotation.

I am a new grad CNM and am finishing my time as a bedside L&D RN, she is not being asked to do anything advanced or beyond the basics. Mostly vitals, head to toe assessments, electronic fetal monitoring, IV starts, foleys, and repositioning as well as some patient eduction and medication education with my direct supervision. She has observed all of this for the first half of her clinical with some guided participation and voiced confidence in each portion before she was asked to do it independently. I am always in the room with her for her to ask questions. For an IV, she gets one poke. If she doesn't get it I take over, same rules I use with all my students.

I have been in communication with her faculty about my concerns and we did have a meeting in which Alice tried to blame me for not making her feel welcome and for "pushing her too hard." Her faculty member literally told her that what I was asking of her was the basics and that she could have been asked to do more.

Alice was told last night that she failed her practicuum and would have to repeat it with another preceptor and in another area. I have never seen such a tantrum thrown by an adult before. I know for sure now that all my suspicions were true about Alice. She skated by in group clinical as never drawing attention to herself. I pity her future patients and hope no one I love ever comes into her care if she ever becomes a full fledged RN. At least I know that I did not take part in passing her along.

I want to offer you sympathy for being put through this. What a horrible situation for that miserable individual to suck you into. Thank you for doing your job even when it is hard. She needed to fail. She deserved to fail. I am glad she failed.

[2mint]

Maybe you should have added something positive about me...”

-I did, with this -Good observation and efforts on your part.”

You observed that she started timidly, then you saw improvements by week 6. We all recognized you put efforts into teaching Alice.

The rotation is not a set amount of weeks but based on hours so you keep saying week 6 or 7...”

-You said hand-holding was the first 6 weeks”, so I hope you could see why assumed week 7” as solo time, as midterm eval time.

You also say I've had 3 or 4 students before, also wrong.”

-I'm sure I was referring to L&D students, as Alice is a student. Two yrs in L&D = six semesters:

1) T/F: Alice is your 3rd of 4th preceptee?

Deduction: 2 yrs in L&D, likely started precepting in Yr #2.”

Not sure why you consider me an inexperienced preceptor..”

-You know that I assumed Alice as your 4th L&D preceptee. So what is your criteria for labeling a fellow L&D co-worker as an experienced L&D preceptor?

I did have discussions with her along those lines...”

-By your admission, they led to confrontations. The communication styles you were using with your early L&D preceptees were Effective. I am pointing out that those communication styles were Ineffective with Alice. Me pointing this out should not offend you. There's no one-size-fits-all communication style.

Would I work with her based solely on your descriptions of her?

I believe thoughtful thinkers do not make decision based on incomplete information.”

-I can't really be anymore clearer than this.

Well, thank you for keeping this back-and-forth civil and further clarifying your position. I hope I have contributed something positive in this discussion. Again, it's just an unfortunate event in which you were forced to take on a student in your last semester.

I believe people questioning another person's leadership/communication skills IS a Good thing.

A good leader in one unit may be not be that good in another unit.