Good grades, substandard clinical performance

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Putting this out there to see if anyone has had some experience or have known an RN student similar to myself. I’d appreciate any impressions you have about the scenario I describe below. Be brutal if you have to … I’m making a major decision and would like to hear good thoughts and brutal alike. Thanks for taking to do so.

The Good

I am in the top 5% of my class when it comes to exam grades and writing assignments. I am comfortable with medication administration and have developed a routine that ensures safety and am prepared (via med cards) to observe for any adverse or side effects (not that I believe I'm not immune to making a mistake but just that I am hyper-vigilant when it comes to med administration). If med administration is late, it’s usually because the instructor is with classmates or the primary care RN is not available to supervise my administration. After my 3rd experience, I am comfortable and sterile hanging IVs and IVPBs. I’m thorough and gentle (if somewhat slow) with wound care.

I do very well conceiving care plans after reviewing a patient's med-surg chart before performing, I am still developing in that respect but my instructors have told me preparation needs only be adjusted a little.

The Bad

The problem arises when I actually have to execute the plan of care. On the floor I get muddled and anxious and my common sense takes a 7 hour lunch break, I get tongue tied and so forth. Here are some examples:

- I am the student nurse who once in the room, forget one or other aspect of the grand plan and end up missing opportunities to teach because I'm busy catching up.

- If I can't take at least 10M to do my head to toe assessment, I will end up missing 2 or 3 aspects of my head to toe exam and disturb my patient again. (Note: I'm super vigilant about ABCs).

- I am the student who is too timid to ask visitors to leave the room in order to do assessments or care.

- If my 18H postpartum patient (whose slept a grand total of 2H after delivering) says she does not want to move so I can do a second of the shift check of her fundus/episiotomy because she doesn't want to disturb the baby in her bed (and declines that I move baby to bassinet), I say "okay" and end up getting sent back by instructor to complete it further annoying this sleep deprived (r/t infant care) woman.

- I don't normally do this in normal life but on the floor I am dropping things left and right and end up needing extra time to swipe them down with industrial strength wipes if possible.

- Bed baths are super slow because I will only gently lift each limb and softly/thoroughly wash. Then I see proficient clinical assistance come in and do everything so smoothly (I have had no other patient care experience other than LPN and RN clinicals).

- My clinical experience write ups are okay. On paper I can describe the patient’s condition and appropriate interventions. My low marks are mostly because I didn't carry the interventions out and because I missed subtle clues and did not adjust my care plan to accommodate.

- I was half an hour late to administer eye drops because when my instructor asked me about the steps - I forgot that I had to hold the inner canthus to let soln keep in the eye. Note: The last time I had given an eye medication was 9 months prior but still my fault because I should have reviewed administration instructions.

My med-surg instructor is fair but verbal and doubts my safety. So after 3 med-surge rotations this semester I have decided that I’m gonna take her’s and another instructor’s advice to find LPN work in a skilled nursing facility (cool because I have a passion for geriatric clients) and reapply next year.

It still sucks sour lemons that it’s either drop with a W or risk a clinical fail (which means an F grade despite a very high B average in all else). But I have read on these boards some great stories of how other students restarted and everything finally clicked so I cling to that hope.

Anyway, what are you impressions based on this lil tale? Again, anything and anyway you say it will be appreciated. At this point I really need perspective if I am to plan my next steps. And I appreciate your time.

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You are a nursing student this all sounds totally normal. You are doing well in classes which is great. What might work for you is getting a part time job working in LTC. This will help you to speed up your personal cares and time manage. But leaving the program sounds a little excessive. They can't expect perfection from a student or even a first year graduate. I don't see anywhere in your story that you have put a patient in any kind of real danger. When you prep for clinical try to plan out your day ahead of time. And keep guides with you for your assessments so you don't miss anything. Just come organized and prepared.

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You are a nursing student this all sounds totally normal. You are doing well in classes which is great. What might work for you is getting a part time job working in LTC. This will help you to speed up your personal cares and time manage. But leaving the program sounds a little excessive. They can't expect perfection from a student or even a first year graduate. I don't see anywhere in your story that you have put a patient in any kind of real danger. When you prep for clinical try to plan out your day ahead of time. And keep guides with you for your assessments so you don't miss anything. Just come organized and prepared.

I agree that it sounds like you are doing whatever you can to protect the safety of the patient. By being gentle while give bed baths to doing gentle wound care, even if it slow. You are a student so right now you probably have a goal of just doing things correctly and safely for the patient. From whatI experienced in clinical, it is ok to be thorough. Speed comes with time. I'm not sure if I understood this correctly. Are you an RN student who is also an LPN?

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NurseLateC. I appreciate your thoughts.so much! Its very encouraging to know. But I have 6 more weeks and dont think I can change my instructor's impression before its too late to withdraw.

I am an RN student who passed first year and qualifies to sit for LPN exam in my state. My school is a 2 year ADN program

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Even if you drop out and work as an LPN, you'll still have these issues with being slow or being too timid. The only way to get better is more experience, and you can get experience as an LPN...but since you're already in an RN program, I don't see any reason to postpone your education.

You'll go through an awkward newbie phase no matter what, you might as well do it at a job that'll be paying you more.

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I agree with the previous posts. You're being too hard on yourself and dropping out of the program is excessive! Talk to your clinical instructor and see where you can improve. Follow up regularly with her/him and make sure that your meeting your prof's expectations and the course's goals. At this point, it's normal to miss things...that's why your clinical instructor is there. In my experience, everyone worried about failing but very, very few people actually did. You had to do something really terrible to fail (like deciding to go off on your own and give medications without your professor or being late to every single clinical).

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You sound very similar to myself! I also am very good with theory and am in the top 5% of most of my classes. I do very well with exams and written assignments, but struggle in clinical. My two biggest problems are confidence and organization (sounds like you may have similar problems). I recently completed a very difficult med-surg clinical. I did eventually pass and actually obtained a pretty high grade, but it was incredibly stressful! I met with my instructor three times to discuss where I was going wrong and ways to correct myself; I met with a classmate to get tips on how she managed her time and stayed organized, and I also enrolled in weekly therapy for my anxiety.

What ended up helping me was focusing closely on very specific instances where my performance was substandard, figuring out WHY it happened, and then developing ways to fix it. Like you, I absolutely hate bothering patients! What my instructor suggested was giving patients choices. ie, "It's okay if you don't want me to assess you right now, but it does need to get done, so would it be better for me to come back in an hour, or a half-hour?" Make it clear that it's non-negotiable, but give the patient some control. This helped me feel like I wasn't intruding as much, and was instead working with the patient.

I also have no other medical experience and tend to be slow with things like bed baths and assessments. Can you practice outside clinical? I found that practicing head-to-toes endlessly on my son really helped me to remember all the steps. I also practice giving him bed baths (he's 3 and thinks it's hilarious). I know other classmates practice on their kids, spouses, and friends.

None of what you describe sounds terrible, to be honest! Your safety sounds good. Have you actually asked your instructor whether you are currently passing, and if not, what specifically you need to change to pass?

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What my instructor suggested was giving patients choices. ie, "It's okay if you don't want me to assess you right now, but it does need to get done, so would it be better for me to come back in an hour, or a half-hour?" Make it clear that it's non-negotiable, but give the patient some control. This helped me feel like I wasn't intruding as much, and was instead working with the patient.

I found that practicing head-to-toes endlessly on my son really helped me to remember all the steps. I also practice giving him bed baths (he's 3 and thinks it's hilarious). I know other classmates practice on their kids, spouses, and friends.

*gasp! I practice head to toe exams on my 12 year old all the time! Why didn't I think of bed bath? Although my kid would have to keep boxers on and do his own pericare (LOL - sorry if inappropriate) because he's pushing 13 and "modest". I'd probably expect him to still take a shower afterwards (what can I say? puberty is what it is for boys). But I'm sure he'd get a kick out that kind of pampering! Thank you!

I also like the soundbite you shared for giving patient choice while not giving patient choice. May I borrow it? Its very eloquent!

And thanks overall for the solidarity - YES organization and nervousness (anxiety in fact) are the challenge. You know, maybe I am taking my instructors words the wrong way. I still have two days to rethink this.

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Sure, borrow away. :) I pretty much borrowed word-for-word from my instructor!

If you haven't already, I really encourage you to ask your teacher whether you are passing & what you can do. I don't think I would have passed if I didn't flat out ask those questions. Then you can direct all your efforts to fixing those particular problems.

best of luck. I so sympathize with everything you are describing! Please update!

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Specializes in LTC, wound care.

When a privacy issue comes up for me, I ask the patient if they would like some privacy before I begin. They almost always say no, but if the visitors are uncomfortable, they take this as their cue to leave the room. And this is kind of chicken, but if I'm not comfortable doing something in front of other people, I say, "We're going to need a little private moment here, if you don't mind stepping out for a little bit..."

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Specializes in Peds/outpatient FP,derm,allergy/private duty.

I don't hear anything that is different from what I and many others have experienced. I was still gently lifting each limb etc with the bed bath on my first job (we did total patient care). As a result I rarely had a lunch break and was less effective overall. As someone who always did well in the academics I applied the same sense of perfectionism to clinicals. I had those 30 Steps or whatever in my brain and painstakingly did each thing. It is a conundrum, because in the real nursing world it's impossible to do it all perfectly though my mind is still insisting that I try!

As far as being assertive with those things you must do to carry out orders or plan of care, you can learn this. Trust me on that one. It doesn't come naturally, and I would never say to ignore an outright refusal, but you can develop a "no nonsense" voice and expression that really is not obnoxious yet gets the point across.

Lastly, if you have two instructors who really think the LPN route is best and you end up taking their advice it is not a failure of any kind. As you mentioned we have people come back who have decided to interrupt their studies for reasons that were the best for them at the stage of life they were in. They share their success stories. You can be that person, too. Hold your head high because to me you sound like you have the personal qualities to be a great nurse. All the best to you whatever you decide!

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Just read through this briefly, but it sounds to me as if order, planning and sequencing are actually your strengths. Your weaknesses are in adapting to the unplanned scenarios, and motor skills. (The former requiring assertiveness, and the latter being quite normal for nursing students with little to no clinical, hands-on background).

For instance, let's take the reluctant PP patient requiring an assessment. Assertiveness. This is where you kindly state that while you really hate to bother her and her new infant, it is necessary for her and her infant's safety. You tell her your goal is to get them both home as soon as possible, and that your assessment will only take a moment and you will be back out the door as quickly as you arrived. Stuff like that.

For the hands-on speed and accuracy in a head to toe assessment, that takes repetition. Remember that the beginning music student sounds terrible: off-key, off the rhythm, and stuttered when practicing at first. It's the same with hands-on patient care. Eventually it becomes second nature. There is a sequence and rhythm to it.

Taking a year off to work as an LPN will cure both of these issues and make RN school much simpler. Just in reading your post, I believe you will make an excellent RN. Don't let a few hiccups hold you back. (Heck, 20 years later and I still get disorganized, scattered and tongue-tied at times. It's why we oldsters still carry "brains"--pieces of paper with pertinent patient info--in our pockets.)

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