The Wicked Politics of Clinical Practicum in Nursing School

[TheCommuter]

Nursing school is not always fair. And, in my honest opinion, the most unfair aspect of the nursing school experience is the clinical practicum portion, also known as 'clinical rotations.' Here is why.

The grades that students earn in the classroom-based theoretical nursing courses are, in most cases, usually objective. Even though the professor who teaches the advanced medical/surgical nursing course might hold personal grudges against a couple of students, the multiple choice exams and quizzes help to even the playing field by giving all pupils a fair chance to demonstrate their knowledge base.

A few exceptions exist, such as the occasional poorly written test question, and the subjectively-graded essay or paper. However, students who are personally disliked by their classroom professor, classmates who are outspoken or opinionated, and those who have been labeled as difficult 'trouble makers' by certain faculty members can still pass (and even do well) in the theory portion of their nursing courses through strong performance on objectively graded tests if they study, use all the resources at their disposal, and fully comprehend the material.

On the other hand, the grades students receive in the clinical practicum portion of their nursing school educations are purely subjective and based almost solely on the opinion of the clinical instructor. This is certainly not a problem if the clinical instructor is fair, balanced, rational, has realistic expectations of pupils, and capable of modulating his or her emotions while evaluating students' performance. It also helps greatly if the clinical instructor possesses a true fondness for transmitting nuggets of knowledge and wisdom to the next generation of nurses.

Let's return to the subjective evaluation of the clinical portion of nursing education. This is not problematic if the instructor is fair and impartial. However, the end result could be a disaster if an outspoken or mouthy student is being taught by a clinical instructor who has old-fashioned values and expects students to obey, conform, comply, respect authority, and avoid painting her in an unfavorable brush in front of others. No matter how intelligent or skilled the student might be, he will almost certainly fail clinical practicum if he rubs his instructor the wrong way.

Many clinical instructors currently work in inpatient settings such as hospitals where they practice procedural skills regularly; teaching students is a second job for these instructors. However, other clinical instructors exist in academia who have not regularly performed patient care in many years. You may notice some of these instructors performing skills in an outdated manner, or quite possibly, they might do something incorrectly.

The outspoken student who announces in front of other students and nurses in the clinical setting that "Mrs. Smith gave a bolus tube feeding while the patient was laying flat in bed" will become a target, even if he is right and the instructor was wrong. This is the same instructor who will be checking students off on skills. This is the same instructor who evaluates students' performance and determines who passes or fails the clinical practicum.

If the instructor is the old-fashioned type who does not like it when students correct her in public, do you think she's going to penalize the mouthy student? If she disapproves of students who question authority, do you think she might give the student who openly questions her a hard time? Keep in mind that if she refuses to check you off on a skill, it is her word against yours. If she insists you failed your most recent clinical rotation due to substandard performance, be cognizant that the director of the nursing program might side with her.

I've revealed the nastier side of the politics that permeate clinical rotations in nursing school. My advice is to pick your battles wisely and tread very carefully. Think before you speak, especially when addressing instructors who make grading decisions that impact your future. The grades you receive in clinical practicum are purely subjective, so do not end up on a faculty member's bad side due to your strong personality and outspokenness. Be aware that no matter how bright you are, the evaluation of one dishonest clinical instructor who dislikes you can set your career back.

Learn to walk the political tightrope. After all, what you know is often as important as who you know in this day and age. Keep that bull's eye off your back.

[TheCommuter, BSN, RN]

I recall during one of my clinical reviews, my instructor saying that I did not act as part of the group. I wanted to say, "your point?"

Something similar happened during my time attending an LVN program back in '04/'05. My clinical instructor would ask, "Why don't you eat lunch with the other girls?" and "Why don't you talk to the other girls more?"

I didn't tell her that the other 'girls' were too giggly, gossipy and immature for my tastes. I didn't mention that the 'girls' spread horrible rumors and talked behind peoples' backs.

It's a sad day when one is expected to conform to the lowest common denominator.

[seconddegreebsn]

I am a good student who has definitely had clinical issues--not with my practice, mostly with grossly unprofessional instructors. One I have now is retired from the hospital where we are doing rotations and she spends the vast majority of her day gossiping with her coworkers. One can never really tell what will push you to her bad side, so I keep.my.mouth.shut. even when she tries to provoke me, and she tries hard, I don't take the bait. As a result, I'm getting a subpar clinical experience where I can't ask questions. It's just a huge waste of my time--I end up asking nurses where I volunteer to help fill in those clinical gaps but they can only do so much.

[Everline]

At my school there is rubric that is supposed to be followed for clinicals, but its use seems to be optional, as every clinical instructor I've had goes about giving assignments or judging what constitutes passing in a different way, sometimes disregarding the rubric all together. We don't get a grade besides pass or fail for clinical and it's rare that someone fails. Theory exams are where the actual letter grade comes from. Having said that, I've had some good clinical instructors and some really horrible ones. Currently, I am dealing with an instructor who is great at organization and seems to know her stuff, but she is extremely moody and tends to demoralize students. I've personally found that in clinicals, the best way to go forward is to smile and keep my mouth shut. I've seen some things in clinical that actually enrage me and/or seriously make me hope to never be in that particular hospital as a patient or a nurse. But I've learned the best thing to do is to keep my mouth shut and smile. I've also learned by observation that by pointing anything out or trying to do things the way we were taught to do them, you will be targeted. It's sad actually that this will be one of the biggest things I learned in clinical rotations.

[pjgal2000]

Best lesson for nursing students. Be quiet. And smile. A lesson I learned again this week.

I am a second degree student who in their previous career was always encouraged to have healthy conversations with my bosses. Not so in ns. Smile and take it. I may have a tattoo put on my body to remind my self.

My daughter is an RN, and now many years later, I am following in her footsteps with a second career goal of becoming and RN in my mid 50s. Her best advice to me was to watch and listen, smile and be quiet, never let them know you know how to do something, just step up and do it! Best advice ever!!

[coolbreezegurl]

I completely agree with this article. I had a similar experience in nursing school, and I have seen first hand how a personality conflict "real or imagined" in the instructor's mind can cause unfair treatment. I had always done just fine in clinicals but 3rd semester that all changed. I had an instructor who decided to hang me out to dry whenever she got the opportunity, bully and berate me in front of my other classmates. I was completely floored by her behavior. Every friday after clinicals I would hold it together and then cry all the way home. The other students used to ask me why she had it out for me and why she was being so rude to me all the time and I could honestly say "I DON'T KNOW." Long story short, this instructor yelled and screamed at me in the med room when nobody else was around. I had enough and told my contact person in the nursing program who was a very fair and kind-hearted instructor. She intervened in my behalf and even went to the dean. I was able to prove the abusive behavior because the clinical instructor had gone so far as to write nasty comments on my care plan that were really unnecessary but I'm glad she did because it was her eventual undoing. Anyhow, they didn't confront her until my clinicals were over, because I was afraid of retaliation on her part. But I had given them a heads up in case she tried to fail me. On the last day of clinicals she actually tried to do just that. She confronted me and said that my skills were not where they need to be, and on and on. I told her "How can you rate my skills when you have refused to help me all semester and are never around to observe what I am doing?" She agreed in a sarcastic manner and on my review wrote "I can't rate this student's skills because she did not come to me for help." She finally admitted to me that she had an issue with me because I was filling out my clinical evaluations wrong all semester. She claimed she tried to correct me and that I just continued to do them wrong. I remember her telling me they weren't right but she did not explain exactly what was wrong, and I thought I had corrected the problem. So instead of her sitting down with me and pointing out what I was doing wrong and making sure I understood, she just assumed that I was purposely ignoring her correction and turning them in the way I wanted to do them. She said it irritated her so much that she didn't want to deal with me anymore. I thought she sounded absolutely insane saying that especially after she had just denied having any issue with me and saying it was all in MY mind. So yes, sometimes you can get an instructor who isn't fair and they can make your clinical life miserable and fail you too. Side note, I started clinicals 4th semester in the ICU, and was told by my preceptor that I had very good skills, and was a fast learner and smart too. I graduated in December and have been working in the ICU ever since. How did I go from being incompetent 3rd semester to a shining star 4th semester and getting offered a job in a high acuity setting?? I think it speaks for itself.

[lrlbug]

I have to agree with this completely. I am about to graduate in a few days (thank God) and was fortunate enough not to have any major problems, but that was definitely not true for everyone! After first semester our instructors did not stay on site with us and provided no feed back at all throughout the semester. We received one mid semester eval and one at the end to result in a P or an F. I came from a professional background in operations and am used to interacting tactfully with superiors as another competent adult. NS was a major wake up call for me in that a few instructors very much treated us like children and tolerated no input of any kind. With our grading structure they could easily fail someone in clinical with little to no reason and pass someone else with identical discrepancies.

[Serenity_Prayer]

Thank you for writing this article, I enjoyed reading the responses. Let me first remind everyone that we, the students, PAY FOR OUR EDUCATION!! Therefore, disrespectful actions from RN instructors should be reprimanded as insubordination. I read many statements regarding the "real world", in the real world an RN's pledge is to abide by the ANA's code of ethics; respect, professionalism, safety etc. Teaching RN's are not excluded, in fact it is my belief that they should be held to a higher standard, bullying is shameful. Anyone who has to demand respect lacks the ability to earn it. Those who are quick to criticize, lack the ability to lead by example. It take less effort and proven more effective to offer direction, rather than irrational insults (wouldn't a "real nurse" know that fear and anxiety is UNHEALTHY)!!

Medicine in general is subjective, which is why they call it “practicing medicine” “medical PRACTICE”etc. The only person I’ve met that knows EVERYTHING is my University MedSurg II clinical nursing instructor. I found her rude and acutely narcissistic – I didn’t like her and she didn’t like me! HOWEVER I WAS PAYING HER TO DO A JOB, she was not doing me any favors, unfortunately the idea that you need them is quite common. While there are hundreds of nursing students applying, there are just as many RN’s qualified to teach. WE ARE ALL PEOPLE, we all have feelings, family, future, hopes and dreams – there is no reason or excuse to validate emotional abuse.

I look back at my experience and would not change a thing. While in my Psyc clinical, me (39yo) and two other nursing students (19 & 20) were assigned to the LOCKED PEDIATRIC psyc unit. When introduced to the unit, there were 20 pts., we were told one of the pts. displayed ‘pseudo-seizers ‘ (which meant she was faking them) another large boy had just beat the crap out of his sister and mother – THEN THE NURSE AND CLINICAL INSTRUCTOR LEFT!! For the next hour or so the pseudo pt. continued to fall as hard as she could hitting her head on the hospital floor. I paged the clinical instructor (nope, no cell??), finally as the only adult in the room I made the decision to stay by the girls side and ease her to the floor – it is my opinion that she would end up with traumatic brain injury or worse. When the nurse came back 3 hours later, she tied the girl to a chair and left her in a black room as punishment. The following week we learned that she WAS actually having seizers - encephalopathy, misdiagnosed as a mental illness.

That was the end of my nursing career! The instructor screamed at me, threatened to right me up and said “they had staffing issues”. Ummm…when did that become my problem? They are now getting paid by insurance and my tuition to have a nurse on staff. I wrote her an email requesting a meeting to discuss the contradiction between Fundamentals and MedSurg, where we are taught to protect the pt then being asked to put all that aside. I explained to her helping that child was innate and I needed instruction and guidance to understand why, in any situation, it would be medically beneficial not to. I never had that discussion and received a “U” for psyc clinical.

Then next semester, in MedSurg II I could do nothing right (subjectively), I was told before Spring break that I was going to fail my MedSurg II for an “Overriding Concern”, specifically professionalism. I had never had a warning, written up, no previous complaints – I had only questioned a safty issue the previous semester. When I grieved the grade, the clinical instructor formally accused me of accosting her in the hall and she felt threatened - I was suspended for 2 weeks. When I returned, this same instructor administered my make-up exam – me & her alone with the door closed. 1^st I thought she was afraid and 2^nd was there nobody on the entire campus besides her to administer the exam? A few days later there was another formal accusation that I stated I was going to “shoot up the college of nursing” – they finally got me out! Later, I was found not responsible for the accusations; by then I had been banned from nursing. I received another “U” for clinical and failed MedSurg class by .3% - 3 failures your out anyway.

I was a duel major, so I was able to graduate with a BA in Psyc (yah, I failed that in nursing…lol). I had a boot put on my car, holds on my account, nursing accessed my medical records (admitted it in writing) etc…PROUD I MADE IT OUT ALIVE!!

Duel major 187 credits, I came across allot of professors with never a complaint regarding my professionalism. At 39, single mother, 60k in student loans; I was told “hire a lawyer”.

So without evidence or probable cause you can be thrown out of nursing school for an “overriding concern”, no explanation, do not pass go and don’t bother looking for justice.

[phoenoryker]

Inherently, this is true of life. I observe people consistently saying what they think people of significance want to hear. Or perhaps the regurgitation of texts written by individuals who lack abstract thought, but had the financial backing to earn serious credentials. It's sad really, people will eventually lose touch with their own identity, but justification lies within appeasing those who hold the keys to the door. At times I wonder if I am a philosopher with no ears to listen to me, or perhaps I am out of my mind. But I do no I am thoroughly exhausted with what I observe in everyday life. But thank god for social media, a playground for small minds to gather together and create the illusion of strength. Another annoyance I have found with contemporary America, no sorry, the world. Good post commuter!

[elkpark]

Thank you for writing this article, I enjoyed reading the responses. Let me first remind everyone that we, the students, PAY FOR OUR EDUCATION!! Therefore, disrespectful actions from RN instructors should be reprimanded as insubordination. I read many statements regarding the "real world", in the real world an RN's pledge is to abide by the ANA's code of ethics; respect, professionalism, safety etc. Teaching RN's are not excluded, in fact it is my belief that they should be held to a higher standard, bullying is shameful. Anyone who has to demand respect lacks the ability to earn it. Those who are quick to criticize, lack the ability to lead by example. It take less effort and proven more effective to offer direction, rather than irrational insults (wouldn't a "real nurse" know that fear and anxiety is UNHEALTHY)!!

Medicine in general is subjective, which is why they call it “practicing medicine” “medical PRACTICE”etc. The only person I’ve met that knows EVERYTHING is my University MedSurg II clinical nursing instructor. I found her rude and acutely narcissistic – I didn’t like her and she didn’t like me! HOWEVER I WAS PAYING HER TO DO A JOB, she was not doing me any favors, unfortunately the idea that you need them is quite common. While there are hundreds of nursing students applying, there are just as many RN’s qualified to teach. WE ARE ALL PEOPLE, we all have feelings, family, future, hopes and dreams – there is no reason or excuse to validate emotional abuse.

I look back at my experience and would not change a thing. While in my Psyc clinical, me (39yo) and two other nursing students (19 & 20) were assigned to the LOCKED PEDIATRIC psyc unit. When introduced to the unit, there were 20 pts., we were told one of the pts. displayed ‘pseudo-seizers ‘ (which meant she was faking them) another large boy had just beat the crap out of his sister and mother – THEN THE NURSE AND CLINICAL INSTRUCTOR LEFT!! For the next hour or so the pseudo pt. continued to fall as hard as she could hitting her head on the hospital floor. I paged the clinical instructor (nope, no cell??), finally as the only adult in the room I made the decision to stay by the girls side and ease her to the floor – it is my opinion that she would end up with traumatic brain injury or worse. When the nurse came back 3 hours later, she tied the girl to a chair and left her in a black room as punishment. The following week we learned that she WAS actually having seizers - encephalopathy, misdiagnosed as a mental illness.

That was the end of my nursing career! The instructor screamed at me, threatened to right me up and said “they had staffing issues”. Ummm…when did that become my problem? They are now getting paid by insurance and my tuition to have a nurse on staff. I wrote her an email requesting a meeting to discuss the contradiction between Fundamentals and MedSurg, where we are taught to protect the pt then being asked to put all that aside. I explained to her helping that child was innate and I needed instruction and guidance to understand why, in any situation, it would be medically beneficial not to. I never had that discussion and received a “U” for psyc clinical.

Then next semester, in MedSurg II I could do nothing right (subjectively), I was told before Spring break that I was going to fail my MedSurg II for an “Overriding Concern”, specifically professionalism. I had never had a warning, written up, no previous complaints – I had only questioned a safty issue the previous semester. When I grieved the grade, the clinical instructor formally accused me of accosting her in the hall and she felt threatened - I was suspended for 2 weeks. When I returned, this same instructor administered my make-up exam – me & her alone with the door closed. 1^st I thought she was afraid and 2^nd was there nobody on the entire campus besides her to administer the exam? A few days later there was another formal accusation that I stated I was going to “shoot up the college of nursing” – they finally got me out! Later, I was found not responsible for the accusations; by then I had been banned from nursing. I received another “U” for clinical and failed MedSurg class by .3% - 3 failures your out anyway.

I was a duel major, so I was able to graduate with a BA in Psyc (yah, I failed that in nursing…lol). I had a boot put on my car, holds on my account, nursing accessed my medical records (admitted it in writing) etc…PROUD I MADE IT OUT ALIVE!!

Duel major 187 credits, I came across allot of professors with never a complaint regarding my professionalism. At 39, single mother, 60k in student loans; I was told “hire a lawyer”.

So without evidence or probable cause you can be thrown out of nursing school for an “overriding concern”, no explanation, do not pass go and don’t bother looking for justice.

Yeah, I used to have to explain this all the time to adolescents on psychiatric units when they were yelling at me about how THEY (their parents) PAY MY SALARY AND SO I HAVE TO DO WHAT THEY SAY. Ummm, no. You are not "PAYING HER TO DO A JOB." You are paying the university for the opportunity to get an education, and the university pays the instructors to use their best professional and clinical judgment and skills to facilitate your learning. You have confused your instructors with a cleaning lady in your home, who is someone you are "paying to do a job," and who is obligated to do things the way you want them done. Also, while you are correct that there are plenty of RNs with credentials/qualifications that would enable them to teach, the reality is that most don't want to, and won't take teaching jobs. Many schools have a difficult time keeping enough faculty to keep the school running. So, actually, yes, the instructors are "doing (you) a favor." I freely admit there are a lot of poor quality nursing instructors out there, but part of that is a function of the great demand for nursing and insane proliferation of nursing schools over the last 20-30 years. If there were a lot fewer nursing schools, they could be more selective about faculty, there would be a lot less competition for good clinical sites (which sounds like it was an issue in your post), and the overall quality of nursing schools would be higher, but decisions were made a long time ago to go with quantity, not quality, when it comes to nursing programs in the US, and we're seeing the results of those decisions.

[ShelbyaStar]

So far I've just had CNA clinical, not NS. I had an instructor that seemed to think of me as mediocre for opposite reasons- I was too quiet. I am introverted, suck at small talk and don't really see the point of yammering at someone that doesn't want to be talked to, though I did chat with the chattier pts.

OTOH there was another student that could do no wrong, seemingly because he was male and a veteran. We got paired up and when we both made a mistake, I was thrown under the bus for it. Meanwhile he made it very clear to everyone in the room, pt included, that this woman's soiled brief was just sooo disgusting. But he got an A in clinical and I got a B, okay then.

Meh. Apparently I didn't make the greatest first impression and that's life sometimes. Maybe I'll try grinning like a crazy person and yammering about the weather next time. Maybe grow a member. She didn't come across as all that friendly either so maybe she was critical of the self she saw in me? Who knows.

[classicdame, MSN, EdD]

well, "fair" is not even a term to evaluate clinical rotations. Not supposed to be fair. Just a lab for you to learn. If you have a better idea on how to allow students to get a grade while in clinical, then suggest it. Sounds like you are focusing on a lot of negativity.

[Serenity_Prayer]

Thank you for proving my point!

1. You didn't take the time to read or lack comprehensive ability.

2. IT IS A FACT that nurses, instructors, faculty and administration salaries are funded by the student tuition.

3. Regardless of position - it is socially unacceptable to act in the manner you appear to condone!!

4. My opinion has been substantiated by new rules of pt. satisfaction...WAIT CLIENT/CUSTOMER SATISFACTION!!

5. I know many many many wonderful nurses who could never be a nursing instructor - ANYONE WITH INTEGRITY AND MORALS could never play the cruel games and politics systemic in nursing schools! They would love to work with students and be a part of their growth...unfortunately this is not what's promoted!!

6. There are wonderful nurse instructors - unfortunately they aren't very popular with the other faculty - hence retention issues.

I wish people could just be kind to one another!!

The good news is you sound like a perfect fit for the job!!!