Totally discouraged by clinicals

**NICU Guy, BSN, RN** · Mar 15, 2014

" I did an assessment on my patient, vitals, and he was pretty much self care so I had NOTHING to do all day, I went in and checked on him every 10 minutes so I could look busy."

I am beginning to sound like a broken record because I have given the same advice to similar threads. Sit down and talk to your patient. If the patient is alone and willing to talk then actually sit you butt down in a chair and talk to them. You will learn to talk to people more confidently, effectively, and efficiently about their health problems. Now is the time to learn to start acting like a nurse. For example, my last clinical we had to do a graded head to toe semi-focused assessment on a patient. After I did my physical assessment, I sat down (instructor was already sitting watching my physical assessment) and asked the patient about when his symptoms started (ulcerative colitis), how often was he having diarrhea before he became to the hospital, consistency of the BMs, amount of blood in the stool, has it changed since coming to the hospital. That lets me know if he is improving or getting worse. If he was improving and then started to have more blood in the stools then he is getting worse again. I asked about his diet. Could he have been avoiding foods unconsciously to avoid having issues with his colon? In addition, you can ask questions about other medical issues and their progression over the years. Now is the time to start building your database of information on the medical issues of all your patients so as you progress in your program and as a nurse so that you will be able to apply it to your current patients. When you start having several patients with CHF or COPD and their signs and symptoms are similar to previous patients with those issues, the disease process and progression will start to click. You have a wealth of information about real people with real issues and not generic descriptions from a book that is only available to you because they are your patient. In addition, start looking at their labs and test results (you should be getting more into this in second or third semester). The labs can tell you a lot about your patient. RBC, Hct, HGB, WBC can tell you if the patient has a bleed or infection and if it is getting better or worse. Buy a lab results book and bring it to clinical. Look up the labs that are high or low and determine why they are out of whack as it pertains to your patient's condition or conditions. No instructor (that is worthy of being an instructor) will discourage you from sitting and getting a health history on your patient. You are at clinicals to learn not only from your instructor or nurse, but from the patients themselves. They are the experts of their disease. They know every minute detail of the disease because they live with it 24/7.

springchick1, ADN, RN · Mar 15, 2014

**On the up side, I did do a successful foley and my patient told me he wanted to marry me, so I couldnt have been all bad :) **

I'm in my 5th of 7 semesters and I have yet to start a foley or an IV. You just make the best of the situation. Volunteer to do what needs to be done and help your classmates.

sadiemae1123 · Mar 15, 2014

Also remember that it's not only important for you to have a clear understanding of the patient's diagnosis, medications, and test results; you also need to be able to convey this information to the patient in terms he can understand. It's important for the patient to know why it is important that certain tests are being done, medications administered, or lifestyle modifications are recommended. Some patients may look to you to answer health questions than their nurse or physician because you have more time and/or will have access to the most up to date resources.

nurseprnRN, BSN, RN · Mar 15, 2014

I had a student once who was a very experienced CNA. She was one of those who was very skilled at CNA tasks and made it really clear that she "knew everything a nurse did, she was just in school to get the credential."

So one day I found her in the nurses' station at 0900 reading a magazine. A nursing magazine, but still.

me: "What are you doing here? What's going on with your patient?"

she: "Oh, he's all done up," meaning that he's been bathed and changed and breakfasted.

me: "Get back into that room and be there. Even if all you do is sit and talk, go be with your patient."

she: Shoots me a look that would etch glass but stomps off to the room. And about three hours later comes back almost in tears. Turns out her patient had recently been given a terminal diagnosis, and nobody had had the time to just sit with him and let him talk. It took about half an hour of near-silence to get up the courage to do it, but he finally started. He talked about his family, his fear, his loneliness at having to make decisions...she ended up holding his hand, and he ended up thanking her for being there for him.

And that, I told her, is why I say not to mistake what tasks nurses do for what nurses are. Naive students often complain about "nothing to do" but that's their ignorance and inexperience speaking. There are none so blind as those who will not see.

RunBabyRN · Mar 15, 2014

I had a student once who was a very experienced CNA. She was one of those who was very skilled at CNA tasks and made it really clear that she "knew everything a nurse did, she was just in school to get the credential."

So one day I found her in the nurses' station at 0900 reading a magazine. A nursing magazine, but still.
me: "What are you doing here? What's going on with your patient?"
she: "Oh, he's all done up," meaning that he's been bathed and changed and breakfasted.
me: "Get back into that room and be there. Even if all you do is sit and talk, go be with your patient."
she: Shoots me a look that would etch glass but stomps off to the room. And about three hours later comes back almost in tears. Turns out her patient had recently been given a terminal diagnosis, and nobody had had the time to just sit with him and let him talk. It took about half an hour of near-silence to get up the courage to do it, but he finally started. He talked about his family, his fear, his loneliness at having to make decisions...she ended up holding his hand, and he ended up thanking her for being there for him.

And that, I told her, is why I say not to mistake what tasks nurses do for what nurses are. Naive students often complain about "nothing to do" but that's their ignorance and inexperience speaking. There are none so blind as those who will not see.

:yes:

YES YES and more YES. You learn SO much from sitting with a patient, an advantage we have over the RN. The patient will really appreciate your time and compassion. It's those kinds of situations that we never forget, and that make us better nurses. Most of us want to make a difference, and this is a big opportunity to do so. Acknowledging a lot of the psychosocial stuff is more significant to a patient than that perfect Foley insertion (though that's a nice touch!). I will never forget my patient that contracted HIV from his wife, lost his job due to his cardiac issues that interfered with his ability to work, and his other litany of issues that led to his admission. He told me the only person he ever sees is his caregiver. No wonder he was so depressed, and did what led to him being there (not a suicide attempt)! I hope that my time with him made a difference. He sure stuck with me.

smf0903 · Mar 15, 2014

Oh my goodness, I could not agree more with RunBaby and GrnTea! I am amazed, simply AMAZED, at how much a patient will offer to you if you open yourself up to a dialogue. I have had a couple of experiences when a patient has told me things that I do believe they haven't told another soul. These things that mold a person, that sometimes make you better understand their life choices and paths they've chosen, things that have led them to the very day you took the time to listen to them. I think it's a privilege that we have the time, at this point, to really sit and listen to our patients.

AOx1 · Mar 16, 2014

If you are bored, that means you have already:

looked up all patient diagnoses and the related patho

performed a comprehensive health history and physical and related your findings to pathophysiology

reviewed and know all about every med (indications, dosages, side effects, administration guidelines, time due, etc)

reviewed and understood all labs, including results, trends, and what they indicate

formulated a complete care plan with prioritization evident

offered patient education after assessing needs and readiness

thoroughly reviewed the chart, including ALL provider notes and treatment plan

reviewed all orders over at least the past 24 hours

assessed discharge and follow-up needs

provided any routine care, or documented that the patient has done so independently if able

provided for patient comfort such as linens, towels, ice/drink/food if allowable

spoken with all care providers

assessed patient's spiritual and psychosocial needs

conversed with and spent time with the patient

offered assistance to others (CNAs, other students, RNs)

documented all the above

If you have not completed all of the above (within the scope of your current skill and experience), then you should not be bored. Be proactive.

RNshorty · Mar 16, 2014

Sounds like you must be in your first med/surg clinical?

You sound very eager to learn which is great! Keep in mind if this is your first clinical rotation, you are not usually give the most ill patient on the floor as you are most likely not prepared for such a patient yet.

My clinical days always depended on the nursing instructor (ask around who is best to take!), the nurse and his/her patient load, the LPN/CNA working and of course my patient!

When you have 'free' time my advice is to:

1. Always, ALWAYS answer all of the call lights you can! This will show that you are a team player and excited to learn, especially not knowing what the call light is for... not always a fun surprise haha Remember, this shows the RN, LPN, and CNA that you want to learn and will take all opportunities. When you show and make this effort, they are more likely to help you and include you with other care.

2. Ask the RN, LPN, and CNA if they need any help. I'm sure they do and most likely will love your help. Get in as many skills you can! An added bonus is after showing how willing your are to help and that you are interested, other RNs may grab you if they have a foley to put in ect

3. Ask your fellow nursing students if they need help.

4. Really look into what your patients diagnosis is and learn about it. This will help you go far.

5. Look into the patients meds! Learn about med classes, side effects, ect.

mama.RN · Mar 17, 2014

To echo the above posts, I think it's really important to be proactive in clinicals. To reiterate, never underestimate the importance of reviewing pt's meds, going over pt health histories, assessing your pt, talking to your pt (I can't tell you how much I am able to always assess a pt just by sitting and talking to them). All the things you have time to do now in the beginning. During my first few clinical weeks, I didn't do much that was too exciting task-wise. But in reviewing meds and checking out my pts, I was able to detect that one pt was being severely overdosed on a med. There were other things that came up like that as well. So, don't think that there is nothing you can do. You never know how you'll end up making a difference. It doesn't always have to be about completing tasks. Also, there is always something that needs to be done, you can always ask a nurse/student what they need help with. :)

SopranoKris, MSN, RN, NP · Mar 17, 2014

I'm ahead of you in the program and I have yet to put in a Foley outside skills lab. Be happy you got to do something! :)

BeenThereDoneThat74, MSN, RN · Mar 17, 2014

Your patients will likely have meds you haven't covered otherwise, and if you administer those, you are required to know them. If you have downtime, this is a good time to research meds, go through the history, sit down with the patient and get a thorough history (I've learned SO much about my patients this way, even if they didn't require me to use my "skills"). I know our instructor would ask us questions about meds that we didn't know, like which labs we needed to know before administering or what to watch for or whatever. We all had the deer-in-headlights look more than once. The best response is never, "I don't know," but rather, "I'll find out." The more stuff you research yourself, the more you'll learn that will really stick. Downtime, if you can't help with other nurses, history-taking, etc, can be used for researching stuff, and there's always something to research!

Many of the replies by the seasoned nurses were very good, but it chose to quote this one, because to me (as an instructor), this is what I expect primarily from my students (and the things they often overlook, based on my experiences).

Meds- you need to know them... ALL of them. Action, dose (is it an appropriate dose), expected effect and side effects (not the nausea, vomiting, hypersensitivity nonsense-

the thing that makes most people not want to take the med). What do you want to tell the patient about this med that is very important (not, "it will lower your blood

pressure", but more like "this is going to turn your urine orange". You must know every med, Even if you are in a day clinical and it is an HS med. why? See if you

can figure that out.

-PRN Meds- why, what do they do, most importantly (for practical purposes) when did the patient last receive it. Why do you want to know this?

Fluids- which one, how much, and why? Is the rate appropriate? What do you need to concern yourself with regarding the fluids? Is the patient putting out urine? Why/why

not?

Diet- not just "patient is on a cardiac diet". What does that mean, and is he eating? If not, why?

Activity order- not just "he's OOB to chair". Is that his order, or is that what he's actually doing? If he's not getting out of bed, why not? Ask him!! Figure out why,NAND what

can be done to get him moving.

Why is the patient still in the hospital? What are we (the team, not the student) doing for him? Look beyond the meds (that he can likely take at home). Has his condition improved or worsened? What would happen if this patient were discharged today? Who will care for him, what will he need at home, how will he follow up, who will cook his meals.

This is what compete care is. It's not a full bed-bath on a patient you can't wait to get out of the room from.

Many of you mentioned talking to the patients- I miss this sooo much! Students are so afraid to talk to them, even the ones who are older (meaning over 24) and have previous work experience. I've heard more conversation from baristas at Starbucks than I have with some students.

I fully understand that you would like more direction. The longer I do this job, the more I see that students are needing more direction. Come right out and ask her- "professor, after I do my vitals, assessment, AM care, what should I be doing next? I want to make sure I'm not missing anything". This statement is very different than "I'm bored", or "I'm really disappointed that I'm not doing as much". It's very likely her answer will mirror the responses here.

Two more things-

Walkie-talkies are often ticking time bombs. My mother in law was a Walkie-talkie, with a ton of medical problems. HTN,Renal, pulmonary. But, alert, oriented, could do many things for herself, skin intact, etc. She dropped dead on the floor of her living room. It's all about the history, not about what tubes,meds and fun stuff needs to be done for them.

The other thing- I am more impressed with the novice student who can tell me everything about the patient, the med, the labs and their meanings and the plan of care, than I am with the one who can start an IV or insert a foley. In my program students NEVER learn to start IVs, and learn foleys in their 3rd semester. So what are they doing? I'm sure many of you would think nothing. Yet, they are tired and stressed at the end of the day, and there is often enough evidence to fail those who are not competent.

mrsboots87 · Mar 17, 2014

So may seasoned nurses have said it, and it is totally true in my experience, but clinicals really are what you make of them. Part of what you will be evaluated on is initiative. I am in block 1 and have only had a few clinical days. The first one, I had an experience like you describe. We are in a facility that has an LTC top floor, and the middle floor is half SNF and half "memory care." I have been placed on the LTC floor for the last few and wont move to the SNF or memory for 2 more clinicals based on room on each floor. Anyway, my first day "sucked". I was nervous and unsure and my patient had quite a few disease processes, but was otherwise very "healthy" in the way she acted. I didn't get to do a whole lot. I went home upset about clinicals and thought that it was all going to suck. Then took a closer look at the day ad the experience I had and what *I* could have done to have a better learning experience. Since then, I have had much better experiences. After I have been with my patient, I let them know I will be stopping in periodically. We chit chat, I get a lot of history, I help them with their daily needs, and try to learn from what they converse with me about. When not with my patient I ask the nurse what she will be doing, or if she needs any help. I have gotten to watch a few things that we haven't learned yet but were cool to see and I learned from them, when the nurse is set to do something I haven't gotten to yet, I ask if I can perform the procedure and depending on time and the nurse, sometimes they will let and at the very least I get to watch. I ask the CNA's if they need any help. I answer call lights. I grab the daily vitals chart and practice the basics. While taking vitals, I ask if I can perform a head to toe for more practice. If I have questions about the pathos, I find the instructor and brainstorm the disease processes and how they affect the body. I also review meds, even ones I wont pass. By the time I go to post conference, I have seen and done so much and learn a lot.

You have to just go out there and take initiative and be proactive about your learning experience. When you feel bored, find the nurse, find a CNA, practice assessments, review your pathos and drugs, or just go back to your patient and chat some more. Make the most of what you get.