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cnmbfa 4,212 Views

Joined Jan 14, '06. Posts: 156 (58% Liked) Likes: 388

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  • Jun 6

    Are they in their early 20's? I teach undergraduate nursing, and I am shocked at the general attitude that they should be given good grades for showing up, and that they generally ignore all constructive criticism. If your not telling them they are great, they don't want to hear it. It is one of my personal pet peeves that the younger generation thinks success should be given to them. Personally, I would talk to the other instructors to see how they are doing in their other classes and clinicals. I don't think there is anything wrong with giving a bad evaluation explaining that they aren't open to suggestions. With that said, the only thing you can do is try to keep a calm demeanor and explain that your job is to give constructive criticism, and that you are just trying to help. For the student who said it was a different diagnosis, I would ask them to define a diagnosis and a symptom. Changing the symptoms does not change the diagnosis, they are two completely different elements. You will have to make a judgement call on if you think the student is becoming a safe nurse. Nurses can have bad attitudes, but bad attitudes that foster unsafe practices should not be allowed to graduate without correction. It will make the school look bad.

    I personally hate having to give bad grades to students, I would love to give all A's. I understand your dilemma because it is easy to give advice, and completely different to actually have to do something. If they are unresponsive to your advice for improvement, it should be stated in their evaluation. Students need to learn that job performance does have direct implications, and that there are no rewards without earning them.

  • Jun 6


    I have a group of clinical students. A few are amazing, a few are average (performing at expected level) and there are three who are not doing well and don't seem to have the self-reflection skills to realize that my feedback might be valuable or helpful to them or how they need to focus their attention. I meet with each individually during the clinical day and review the clinical log he or she submitted the week prior, going over it in detail. Two of them get mad at me and seem like they feel attacked, and will argue silly points with me (for instance, they have to include two different nursing diagnoses, and one submitted the same one twice with two different "R/T" and tried to argue that that made them two distinct nursing diagnoses...and the list goes on). The third just says "ok,ok,ok" throughout all my verbal feedback and then nothing changes. All the rest ask pertinent questions, show insight, make their nursing thinking clear on the logs, get better every week. A student telling me "You said that last week" in a scornful tone is just not leading me to think that she would be a safe nurse...but attitude is subjective, right?

    I can't figure out why these particular three have such a difficult time with feedback. This is not even a graded assignment we are talking about. It's just a log, a way to guide their thinking toward the nursing process, which I can facilitate if they will let me.

    Any ideas or feedback for me would be appreciated.

  • Jun 6

    It is always difficult to fail a student, and it sounds like both you and the program took several opportunities to bring her up to snuff. When grievous clinical errors are made, or the student is failing theory, we put pen to paper in the form of conferences outlining the deficiencies and what tools the student can use to help learn from the situation so that it does not occur again. The student can appeal all they want but if the evidence is there in the form of a paper trail outlining patterns of deficiencies without improvement she most likely will not be successful.

  • Jun 6

    It's 0653. I pull up to the hospice unit, clock in, fill my coffee mug, and get my nursing brain printed out. At 0700, I count narcotics and take report on six patients. It's going to be a busy day, one of those days where I must control the chaos, take the time to support patients, complete as many of the thousand tasks set before me as I can, and be prepared to deal with the unexpected.

    I work in a palliative/hospice inpatient unit, a place where patients come when they are in crisis,can't be cared for at home, or simply have no place else to go. One of my patients today is in indigent man who has no one in the world.We cannot locate his family. We don't even know his real name. He slipped into a coma yesterday and is non-responsive. We take care of him, call him by the name we think he has, and witness his last hours or days.

    In the room next to the indigent man is a very, very old woman, the matriarch of a large Native American family. Her family comes and goes all day. At any given time there are 5 or 6 people in her room on folding chairs. Children walk the halls as if they own the place, but they are respectful and polite.Volunteers keep the cookie jar full, the coffee pot brewing. The family has filled the kitchen with potluck dishes. They tell the staff the food is for us, too, and the family members of other patients if they want it.

    As I head towards the med cart, the smell of bacon fills the unit. A CNA is cooking for one of the patients who is still eating. I meet the wife of one of my patients in the hallway. She's tearful and scared. I have four patients who need scheduled meds now, but I take her aside and listen to her for a few minutes. I say the only thing I can say with honesty: “I know this is hard. We are here for you.” The tears start to spill and she turns away and heads to her husband's room.

    I run to the med cart and pull the meds. One of my patients, let's call him Robert, is actively dying. I admitted him three days ago and have not seen him since. He's a younger cancer patient. His cancer moved fast. Three months ago he was living a full life. When I admitted him he was still talking, expressing his grief, telling his horrendous tale of all the invasive treatments he had received. I could tell how traumatized he was by the expression on his face as he was reliving his recent ICU experiences. He was admitted directly from the hospital. He said that after the last treatment he just wished he could die right then and there. I asked what were the most important things we could do for him here. He said he wanted quiet,no alarms, no more tests or treatments. But most of all, he wanted peace. I told him, “This is not a hospital. You are in the driver's seat here.” I pointed out that there were no alarms here. I said we would try very hard to make sure he was comfortable and at peace.That was two days ago. Robert was now actively dying.

    I am a newer hospice nurse. I am still learning the ropes. I left my successful job in a pediatric ICU/step-down unit three months ago. I had one very hard year as anew-grad nurse, two very good years, and two years of slow burn-out.In the ICU, I often took the dual roles of life-saver and torturer.Many times the torture was worth it. But many times it was not. My shifts were task-oriented, intense. They had to be. I focused on the monitors, drips, airway, vent, labs, juggling all of that very carefully. The patient sitting in the ICU bed was a human being whose feelings were, at that moment, secondary to the more immediate and important need of saving their life. And sitting in the dark corner of their room, scared and silent, was that patient's parents, living their worst nightmare. Once in awhile I would try to find a break in the million tasks I needed to do on time, so I could go and explain what was going on, offer to get them a cola, or validate their feelings. But more often than not, I just had to let them sit. I didn't have time. I went into nursing to heal. And while the ICU certainly did that much of the time, I became burned out. I lost the heart of nursing. Thus, my calling to hospice.

    As I enter Robert's room this morning,I notice his breathing is heavy, his forehead wrinkled. I call his name and he opens his eyes. They search the room, unfocused. I put my face near his and smile and say, “Hello, Robert. Good morning!”and his eyes find mine for a second and hold them. He relaxes and smiles, and then his eyes let go of mine and close. He grimaces again. His breathing is still heavy, chest congested. I give him his PRN dose of morphine and ativan, but I see very little improvement. I leave to go email the doctor on call to ask for an increase in Robert's medication. I still have patients who need scheduled meds but Robert urgently needs a med adjustment. He is, at the moment, my first priority. Two family members approach Robert's room. I know it will pain them to see him in such distress, and I tell them I just contacted the doctor and more medication should be available very soon.

    I fly into my last rooms, give the scheduled meds, see that they are stable and doing fine, and log into the computer to check my email. An order change for Robert!Robert, luckily, had central line access. I give the meds immediately and stay to watch as he relaxes, his breathing becoming less labored,and his face more peaceful. I tell the family I want to position him on his side, and they hold the pillows for me. As I am positioning his cancer-wasted body, I point out the mottling of his knees and feet, how they feel cool, and how he is sweating, and how these are all signs that death is approaching. They bravely listen and nod in acceptance. They ask, “”How long do you think he has?” I tell them, “Each person has their own timing. It could be very soon. I am guessing hours to a day or two. But I think it will be sooner rather than later” I tuck him in and put my hand on his forehead,something I do with all my patients, as tenderly as I do my own children, and I say a silent prayer for peace. Then I leave and close the door behind me.

    I navigate my way past the crowded hallway filled with family of the Native American matriarch, and I hear singing from within her room. I go into my last room, a woman whose pain crisis is now being managed well. She has a few more months, and hopefully she will be able to remain comfortable. She is snuggled with her small dog in her bed, her son at her side. I workaround the dog in doing my assessment. She is due to go home later today. I return to my nursing station, peeking in on each patient as I pass their rooms.

    I have a mountain of paperwork to do.How will I ever be able to do it all? I need to print out medication instructions for the patient with the dog. Before she leaves I will have to find another nurse to count her controlled meds with me. I still need to enter the email order of Robert's increased medication doses in the paper chart, to be co-signed by another nurse, and then print out a new MAR sheet for that order and sign it. I still have wound care to, and in another 30 minutes it will be time to turn everyone with the CNA's assistance.

    As I am working behind the stacks of charts and papers, the sad wife comes up to me. “I'm sorry for interrupting your work . . “she starts off. I stand up and come out from behind the counter. I tell her, “You are not interrupting me.It is my job to support you. That's why I'm here.” She relaxes and asks questions about what steps to take next, what to expect. Some of her questions are better answered by the social worker, so I escort the wife back to the room and go and talk to the social worker about her needs. As I make my way back to the desk, I peek in on the patients again. I notice our chaplain sitting at the bedside of the indigent man, singing a hymn.

    I continue to do my paperwork and emailing. Something tells me to look up, and I see Robert's door opening. His uncle steps out, and he has that look on his face that I have gotten to know: shock, grief. I reach for my stethoscope as he approaches. He says, “I think Robert's gone.” I walk in with him,find the bed surrounded by loved ones, all silent. All eyes are on me. I can tell from first glance that he's lifeless. I take Robert's hand in mine and hold it gently, feeling for a pulse. I put my stethoscope on his chest and listen. Everyone holds their breath.Silence. I listen for a few more seconds, then look up, make eye contact with everyone and tell them, “I'm so sorry. Robert is gone.” The tension breaks. Tears are released and pour down cheeks.People hug each other. There is relief in the long, drawn-out death.

    I stand to the side for a moment and wait for the first wave to pass. I say, “Take all the time you need with Robert. We are here for you. Please come and find us if you need anything, anything at all.” The uncle nods. I turn and close the door quietly. I go to our patient census board and wipe out all the details of Robert that no longer matter, leaving only his name. I write in, “TOD: 1246.”

    I give out my next round of meds,continue to assess my patients, update the doctor. I am invited to take some lunch from the buffet of the Native American family, and even though I brought my own lunch, I know they have a need to feedus. I fill a plate as one of the sons nods approvingly. I go back to my desk and start to break down Robert's chart and prepare to destroy his controlled meds.

    A woman rushes in, tearful, and asks where Robert's room is. I stop her and ask if someone has called with an update on him and she nods and said, “Yes, I know. He just died.” She starts to turn to the room and then stops and turns back to me. She puts her hand on my forearm and asks, “Was it peaceful?Did he go peacefully? Because that's all he wanted.” I look her in the eyes. I can honestly say “Yes, he did. He was very relaxed and breathing easily, and he was very comfortable.” Tears form and she says, “Thank you. Thank you” before the words leave her. She enters his room.

    Two more hours pass. Robert's family tell me they ready for me to call the mortuary. I make that call, and go back to the afternoon tasks. I perform my wound care, finally: an elderly woman who was found down, broken hip and and multiple severe skin tears. She never fully regained consciousness. It is clear that until her accident she had been in good health. Her family is still in shock. They asked how long it might be. I tell them that once a person stops eating and drinking, as she had three days ago, it would be about a week, give or take a few days. Her daughter nods bravely.I reassure her that her mother appears comfortable and we plan to keep her that way. She swallows hard and says a quiet, “Thank you.”

    I send the woman with the dog home after giving report to her home nurse. In my later afternoon rounds I notice that the indigent man's breathing pattern has changed. His head is arched back and he is grimacing slightly. I moisten his dry mouth and lips and administer a PRN dose of morphine, turn him on his side, tuck him in, and touch his forehead with my prayer before leaving his darkened room. I do another round of scheduled meds, and some PRN's, too.

    The man from the mortuary is here to pick up Robert. I have him sign some forms and take him to Robert's room and introduce him to the family. A few minutes later Robert's body is wheeled out. His family lingers in the lounge. Each of them hugs me or shakes my hand and says thank you as they trickle out. I have so much paperwork to do, but I stop those thoughts as I take the time to shake hands with them. It's hard for them to leave, to know that it's over. I am helping them to do that.

    It's dinner time. The Native American family offers (insists!) that we take some more of their food, so we all do. I make my last rounds. I notice the indigent man has slipped away as quietly and anonymously as he walked through his life. I confirm his death. TOD: 1803. I remove his pillows and position him straight. I call the county's indigent burial number and know that someone will pick him up soon. I set aside his chart. The night nurse can finish his discharge.

    My charge nurse hands me a sheet: “We have another name,” she says. I take report on the patient who will going into Robert's room in about two hours. Our unit is in high demand, a revolving door.

    As a hospice nurse, I have to continuously strive to not get lost in the tasks, to prioritize, and to do the most important ones well. Hospice nurses have a lot of“wiggle room” to make nursing judgments. Each patient is different, and so are the rules for each patient. I'm still adjusting to this shift in model of care, still untangling my mind from the ICU. Slow down. Meet the patient where they are on their journey,walk the pace that they set. Look at the patient, not the machines.

    It's 1905. I count narcotics with the oncoming nurse. I give report, trying to pace myself to give the most important details about each patient, but not so long that the important things get buried. 1930: I should be done, but I'm not. I take my paper charts to the break room and I finish writing out my narratives on on each chart. The Native American matriarch, the woman with the broken hip, Robert who is now at peace, the woman with the dog, the man with the grieving wife, and the indigent man. I relive my day with each of them. It hits me, as it does almost every day,the sacredness of the work I do, the journey I am allowed to walk with the patients, and the job I have of facilitating that journey so it is as peaceful as possible. And knowing that it just as much as honor to be there for the last breaths of life as it is to be therefor the first breaths. And then there is still paperwork to do. I pick up my pen and finish charting.

    2003: Finally I am done. Am I forgetting anything? I hope not. I clock out. As I walk through the lobby, some of the members of the Native American family wave to me and call out “Thank you! Goodnight!” I enter the crowded parking lot. I see four people hugging each other and crying. The county mortuary van pulls up and parks. He is there for my indigent man. I get in my car and head home down the dark streets. I see life all around me: a family out for a bike ride, people pulling out of the grocery store parking lot. I call a friend and catch up as I fight fatigue. “How was your day?” she asks. I have so much I could share, but I'm so tired. I have no words. I have a thousand words. I finally settle on saying simply, “Good. I had a really good day.”

  • Jun 6

    If you are looking for guidance on this forum it's best to shoot your own ideas out and ask for feedback...when you leave it open-ended without showing your effort, it seems like you're expecting others to do the work for you.
    Just a helpful tip...

  • Jun 6

    Welcome to all nurses I see you just joined. Be aware that on this anonymous website there's no way for you to actually prove that anybody here is a nurse. And when you are supposed to interview A nurse, usually the instructor intense for you to find a real nurse and interview her in person face-to-face.

  • May 1

    As previously mentioned, these students will be weeded out when it comes to NCLEX. You get what you put into your education. As infuriating as it might be, let these people be a motivation to you as what kind of nurse you don't want to be. Your integrity and honesty will shine. Continue doing what you are doing and you will do wonderful. They will get what they put into their education and they will be saddened to learn that this type of behavior is not encouraged or tolerated in the work force.

  • May 1

    A few things came to mind as I was reading your post- I hope I can remember them all in mine...

    First... I am soooo glad I'm not in school anymore! It was one of the most difficult & challenging times of my life- but ultimately it was exhilarating & satisfying as well, especially when I was done.

    Next, everyone is right- nursing is like no other major. I went from pre reqs where you learned a subject & were tested on the subject to nursing program to where they taught on some stuff, some you were expected to read/learn on your own (& yes, massive amounts of info) & the tests were nclex style where not many questions were content based but critical thinking as to what you would do with the info you learned. It was a shock to my brain & took me- all of us- a bit to get into the groove. (My advice to all nursing students is to get nclex books/ apps on your phone & answer as many questions as you can in your copious amts of free time to train your brain)

    Which leads to the next point... Most instructors do want you to learn. Yes, I too had that one sadistic instructor that was rude, condescending & terrorized everyone. I think there is one at every school. But overall, schools are mainly concerned with nclex pass rates. That's what attracts students, keeps their accreditation & brings in more money.

    When a few students are failing abysmally, they aren't thinking of losing next semesters tuition, they're thinking- and rightly so- if that student manages to graduate, they probably won't pass nclex & it'll look bad on them. Which can cause them bigger problems than a couple of tuition payments. Harsh, but true.

    Tell your friend it'll look better if she resigns than fails out, btw. She can always re-enroll & try again.

    Ok- thats all I can remember that I wanted to say, except that I wish you heaps of good luck and just keep putting one foot in front of the other. It won't last forever. It's difficult but very much worth it!

  • May 1

    Quote from Pangea Reunited
    If someone is failing every exam, regardless of the reason, they're far from "solid". Honest feedback in not inappropriate, even though it may not feel good to hear. Some people really are better off cutting their losses and moving on to something they're more capable at.
    I totally concur...I would hate to sound unsupportive, but we all cannot be anything that we want to be. This is a cold, harsh reality.

    My neighbor Bobbie might yearn to be a nurse. She might have even been accepted into a nursing program. Yet, if she lacks the academic horsepower to comprehend the material and apply it astutely to answer exam questions at the analysis level, she will not be a nurse. Intellect cannot be taught to a grown adult in college...sorry.

    It is fortunate that not everyone can be whatever they want to be. Otherwise, we'd have 20 million nurses in America, leading to a scarcity of jobs, lower pay, and deteriorating working conditions. Failure has positive aspects because we can learn from it, try again, or gravitate toward something else that suits their capabilities.

  • May 1

    You might find yourself as shocked to the reality of working conditions and expectations as you are with school.

    And no one should be able to buy their way through school. The fact that they're discouraging her seems the ethical and pragmatic thing to do.

  • May 1

    Florence Nightingale was, first and foremost, concerned for the wellbeing of her patients. And if you take a peak at nursing history, she was incredibly picky/borderline discriminatory about who she would allow to be a nurse.

    Instructors care about us, but their jobs are NOT to ensure we're happy. Their jobs are to ensure that competent people are caring for patients.

  • May 1

    ^ This x 1 million.

  • May 1

    If your goal is to avoid "difficult" then skip nursing altogether.

  • Aug 7 '15

    There are some great videos on YouTube that breakdown the best way to read nursing textbooks.

  • Aug 7 '15

    Oh, so textbooks are boring? Really? I suppose screens are less so. Lucky for you that the NCLEX -- which tests for a lot of stuff in those boring ol' books written by experts-- is done on a computer screen. I'm sure that will make up for not having done the reading, right? Let us know how that works out for ya!