Failing a student in clinical

[Berkshire1995]

I had a student in the last stretch of clinical before he goes into a preceptored clinical. In the preceptored clinical, they are basically on their own and can ask questions to the preceptor. Graduation is in June. This student read an order for insulin wrong and drew up 6 times the ordered dose. The student commented that it seemed like a bit much. I was watching and asked the student to read the order again. He continued to say the wrong dose. I told him he could have killed this patient. The student commented that he is "there to learn, that's why I pay tuition." At this stage of clinical, I find this to be unacceptable and dangerous. I could not pass this student. He had been warned for weeks that he needed to improve. He received weekly written evaluations and we discussed ways to improve. He is now contesting this and feels that I was not fair. Your thoughts?

[*4!#6]

I am in an ADN program and I am flabbergasted at the OP and the comments. This would not fly in my program at all!

Not all BSNs are like this person. I think it all depends on the person, their maturity, and the values of their program. I have worked in healthcare before my bachelor's and my school and professors are very clear that we are in no way better.

I deliver meal trays at the hospital. A student from a local college (not BSN) approaches me with a dirty tray in her had, literally drops it into the med prep station counter in front of me, and says "Get rid of this." And walks away. If that had been me, my professor would have skinned me alive.

Anyway, this person the OP is talking about obviously has a bad attitude and would be dangerous in a practice setting regardless of their level of education.

[azhiker96, BSN, RN]

It seems to me the school has a simple decision. Either they condone that student's performance or they don't. I suspect as long as you are not willing to change your objective description of the problem, the school will not want to accept the liability of passing that student.

[That Guy, BSN, RN, EMT-B]

Owned up to the mistake and recognized the danger in it = maybe pass

His attitude and the way he presented to you = automatic fail

We all made mistakes in clinical and in school but its how you deal with it that sets you apart from this kid and nurses that make it through and are good.

[Whispera, MSN, RN]

The student had been warned for weeks that he needed to improve. He drew up 6x the ordered dose and read the order incorrectly a second time. He seems to feel paying tuition takes precedence over being appropriate. He would have been more on his own in the near future....

Let me be devil's advocate, and all these thoughts and the questions are rhetorical...

Did he argue over giving or not giving the insulin or did he accept that he was wrong? I think his response could have been a bit of an attitude that some have that isn't intentionally saying he's without fault, but more of a, "wow, I'm here to learn and now I have." I wasn't there, so I can't judge completely. Was he voicing entitlement or a different way of accepting the situation?

The fact that he would be going into a less-observed clinical next bothers me, though, since if he didn't ask someone to verify insulin dosage, he very well could kill a patient. I'm not sure I'd fail him, but I'd be watching him like a hawk and his autonomy would be tiny until he would show me he had earned it. I don't know how your school is set up to monitor the preceptored students though, and maybe watching like a hawk isn't possible?

Insulin doesn't require another person to verify the dosage where you take your students? The verification is there so such errors don't get injected. If that policy isn't in place, it should be! Was he ignoring it? Did he come to you for verification?

Would you fire a coworker who responded as he did (if you could fire) or would you work to make sure the coworker knew what was correct, so it didn't progress to injection, and so the coworker would be more careful the next time?

Other than this incident how has he improved or stayed the same, or gotten worse? How does any improvement stack up against the non-improvement and glaring errors?

[lumbarpain, ADN, RN]

Sounds like he needs an attitude adjustment. I think you did the right thing in failing him, when he said " it seemed like a BIT much" was a red flag that he wasnt going to ask about if the dose was wrong or not, plus he continued to repeat the wrong dose? I would have rewritten the order on another piece of scrap paper and ask him to read it again.....maybe he was seeing something else on the original? I know I came across some horrific handwriting in my days.......on ALL levels of healthcare, from social workers to doctors!!!!! WAS HE going to question the order? Did he FEEL something in his gut that the dose was drawn up incorrectly or written wrong or anything or did he just assume? He definitely sounds like a major accident waiting to happen and when you said to him "you couldve killed a patient" He comes back with" I am here to learn and I pay tuition? So...to him killing a patient is a part of the learning process!!!!!!!! NOPE, take your stethoscope and go home.!!!

[Merlyn]

It seems to me the school has a simple decision. Either they condone that student's performance or they don't. I suspect as long as you are not willing to change your objective description of the problem, the school will not want to accept the liability of passing that student.

Do you want the responsibly of passing that student and maybe with his next injection of insulin kill someone and give lip to anyone that points out his mistake. it's not black or white, it's shads of gray. Perhaps if he was more caring he might still be in school. But he wasn't. We could go on and on with the 'What if's"

[OnlybyHisgraceRN, ASN, RN]

I can't believe the student acted this way. As nurses when we make mistakes the first thing we need to do is realize our mistakes and take accountability.

[SHGR, MSN, RN, CNS]

I apologize if the question was answered but, is it possible this dose was written with a trailing zero - 6.0- or as 6u instead of spelling out units? Both of these are unacceptable abbreviations per JCAHO and have been for some time, for exactly this reason.

I am not condoning the student's response, but I am wondering if this could have contributed to any confusion.

http://www.factsandcomparisons.com/assets/hospitalpharm/jan2006_jcaho.pdf

found this link, it's from 2006 already.

[azhiker96, BSN, RN]

I apologize if the question was answered but, is it possible this dose was written with a trailing zero - 6.0- or as 6u instead of spelling out units? Both of these are unacceptable abbreviations per JCAHO and have been for some time, for exactly this reason.

I am not condoning the student's response, but I am wondering if this could have contributed to any confusion.

http://www.factsandcomparisons.com/assets/hospitalpharm/jan2006_jcaho.pdf

found this link, it's from 2006 already.

Good points although if the order had been written as 6.0 or 6u then the student would have drawn up a dose 10X too large instead of 6x. I'd guess it was a sliding scale calculation that was done incorrectly but the OP will have to answer for us to know for sure. I agree that the student's response is not what we'd want to see in a fellow nurse.

[cnmbfa]

You absolutely did the right thing. Your DUTY is to protect the public, and his response speaks volumes about not either understaning or caring about putting a person in danger. It sounds like you did all the right things re: documentation, so his appeal should not go very far.

I have been in a similar situation recently, and several times in the past. While htis is not easy, it is simply waht we MUST do.

[prof joe]

On the very first day of clinical my students get the lecture of being part of a profession nurse and what it takes to be professional, therefore the students are professional (nursing) students. I would have failed the student earlier for nonprofessional attitude. In your situation and using your own words of "The student commented that it seemed like a bit much" shows an aspect of critical thinking on the students part. I would have failed the student for other reasons but I would have to explore why the student thought the dose was wrong and then found where the student went wrong in reading the order twice.

[jennabond]

Best wishes with this matter. It sounds complex even though the students verbiage was simple. I think your post gives us all a way to examine how we would handle this matter if it was in front of us.