Reaching a dedicated, intelligent nursing student who has trouble with clinicals - page 2

by onewill 4,350 Views | 20 Comments

I am a 3rd semester RN 'A' level student. I have discovered that though I am good with theory learning and do well with NCLEX study questions, I am struggling with my clinical performance. It seems that in carrying out patient... Read More


  1. 2
    Hi,

    I am in my final semester of an and program and taking 4 patients at clinicals. I assess, give all meds (but don't have access to the Pyxis) chart, call MD's and pharmacy, and transcribe all new orders. The only way I can get through the day is by staying organized. I always have one patient brain sheets and a pink, black, and green pen. I tried using brain sheets that had multiple pts per sheet but I would always run out of room. Here is a break down of my day:

    Per facility policy, meds are usually due at 0900, and 1300 or 1400. They can be given one hour before and after. Assessments need to be done by ten and charted by 1100.

    Clinical is from 7-3. I arrive at 6:15. Usually the assignment sheet is done by 6:30.

    6:30- pick 4 pts all from the same nurse. Quickly find the kardex's and copy as much basic info as I can onto my brain sheets. This is usually just name, age, sex, admitting dx, previous dx, diet, activity, and allergies. If the night nurse I got the kardex's from is cooperative I will ask if anything out of the ordinary happened with these pts. Most of the time the night nurse will give me a mini report on them. Then I go to the computer and will quickly look up labs and only write down abnormal labs.

    7:00- find the day nurse and listen in on report. Tell the nurse I need the MAR's. Most of the time they won't hand them over right away, but I at least look at them and write down the times the meds are due for each pt on their brain sheet in pink pen. I will also write done blood sugar checks and insulin in pink so it stands out.

    7:30 (or when report is done and I looked at what times meds are due)- is the pt and iv check- grab a bunch of flushes and go to the pts rooms one by one. Wake them up if they are still sleeping. Introduce myself, check that iv is still good and has a date on it. Flush it if there is not fluid running. Check that tubing has a date on it. Do a 2 minute focused assessment on the pt ex: if they are there for pulmonary reasons, listen to their lungs and ask about SOB- that's it. Just make sure they are stable. If they are talkative dont get stuck there. Just politely tell them you just came to make sure they were not in distress and will ba back in a hour to talk to them. I also ask about pain level so I know if I need to bring back pain meds. I write the location and gauge of the iv site when I am in the room so I can chart on it later.
    P
    I try to spend no more than 5 minutes in each room at this time. After I'm done go chart one or two sentences in each chart stating the pt is stable and no signs of distress, ect. Check the charts for new orders.

    0800- find the nurse, tell her the pts are stable and ask them to get the meds out for you. I grab one lab bag per pt and get all heir meds out at once. Each pts meds go in a separate bag with their room number written on it. I like to start with the most complicated/time consuming pts first. Start ASAP with the meds and get them all done one by one. I cross out the 0900 time in my brain sheet as i go. When I am giving meds to the last pt (usually 0915 or 0930 by this time) I wil also do my full head to toe assessment. I will write the assessment in my brain, then go chart that assessment. If anyone has insulin I will give it right away.


    0930 ish- I will go do my assessments on my other three pts and write them on my brain sheets.

    1000 ish- Sit down at the computer and copy my assessment from the brain sheets.

    When I am done with charting assessments I will check for new orders again and read the doctor notes and do more research on the pt. if there is anything I need to look up or do gets written in green on my brain sheets. I am usually done charting and researching by 1100. If the pt has 1200 meds I will get these ready. If I don't have any meds due until 1300 I will take 5 minutes to eat my sandwich.
    Then on to the afternoon meds and pt requests.

    Usually it is just the morning that stresses me out. I still can get thrown off if I have a extra needs pt, if the meds are missing from the Pyxis, or if my patient is not doing well. I try my best to recover from those situations and save the rest of the day. I always make sure to keep the nurse informed, and ask them advice if you need it. Often, when multiple things come up at once I will tell them the situation and ask how to figure out what to do first. I am usually pretty lucky and as long as I keep the nurse well informed, they are usually pretty good about answering questions and giving advice. If they are not willing to help I will make a mental note and try not to pick their pts again.

    I used to keep a written schedule for myself, but now I am able to do it in my head. As long as I can stay organized I am usually ok. If I start to get thrown off on time I will take ten minutes to myself, de stress, make a list of what to do in what order, and get to it. If your instructor is stressing you out or you are getting overly anxious when talking to them, tell them you need just a second to clear your brain, turn around take a few deep breaths and just keep going. I had the instructor from hell last semester and had to do this many times. If you feel like they a expecting more of you but not telling you make an appointment with them and talk about it. Find out exactly what they expect of you so you can give it to them.

    It is very tough, but you can get through it. Just remain calm, organized, have a plan, and keep everyone informed. It's just a short period of time. School will soon be over and far behind you. Good luck, keep us updated.
    onewill and Tait like this.
  2. 0
    Thank you BSF for stopping by with your days layout
  3. 0
    We do work up to four patients by the end of the semester, not the beginning. First day or two, it is one patient. Second week, it is two and we stay there for a couple of weeks then it is three patients for several more weeks, then four towards the end. At the time I withdrew at 8 weeks, I was having trouble going from 2 to three patients - I was beginning to make mistakes and getting frazzled because I was starting to fear my instructor and my brain would just freeze. Interestingly, my peers in other clinical groups with other instructors were not hitting the wall I was hitting in this particular semester.

    My first two semesters we worked from one the first semester to two the second semester. I didn't have this anxiety those first two semesters. My instructors were tough but I didn't fear them and they gave good and positive feedback in addition to criticism. They helped me believe in myself. So to answer your question about new floors - We get rotated on the different floors in an unpredictable manner at the beginning of the semester so by the end of my shift on one floor, I have gotten used to the layout but one week later, I would be on a different floor. Then might end up on that original floor the following week but I've lost some of my familiarity by then and there is some backtracking and retracing steps again. Many of us could be released to work with our primary nurses. My instructor kept a tight hold on me which I believe made matters worse as she wasn't bringing out the best in me - so was helping to create crisis. I really needed a breather from her so that my brain could function like I knew it could. But again, I don't do well if I am pushed more quickly than I am ready anyway so it made sense to try and redo this semester, recover from my downfall, and get a new instructor for the fall. I hope I will be in a better place to handle the demand...also other instructors may be more patient and allow for individual differences.
  4. 0
    You rock black sunflower! I am going to save what you've written (I'm new to this and must figure out if I can copy and paste what you've written (do I have you're permission??) so that I can apply it to my typical shift (assignments are NEVER completed by 630 so I would have to adjust accordingly and most night nurses will only report once, not sooner and when they're good and ready -- when they're dealing with a student. Some are more cooperative). You've given me more guidance than I have gotten from my instructor...when we started the third semester, she said - "this is the semester that you need to 'show us what you got' " meaning we were expected to be able to know to do this as you've laid out. Ostensibly within a couple of weeks anyway.
    I have done as you've recommended and then some with my instructor in terms of speaking to her in person, outside of clinical and after clinical to let her know how I best learn and that the pressure I was beginning to feel was starting to become the barrier, not the learning curve itself. I AM going to hang in there and hopefully my reputation with the rest of the instructors for next fall isn't too sullied that they will give me a fresh start to be successful. Thanks so much for your time to offer such a thorough plan!
  5. 1
    When I was in clinicals 6 or 7 years ago, we were assigned our 1 or 2 patients the day before. We were allowed/encouraged to stop by the hospital unit the night before to look over their charts, med lists, care plans etc. That helped TREMENDOUSLY. I'd write down their diagnoses, meds & history and read up on everything, then arrive in the morning not totally clueless!

    Is there any way to ask if this is possible?

    Also, BE ASSERTIVE with your instructor. If the hospital policy is 1 hour before/after med admin, and she says otherwise, look her right in the eye, smile, and say, "hospital policy dictates that one hour before or after is acceptable." Some might tell you not to push the envelope. I say push it when you are definitely in the right. I did, and not only was I left alone, my instructors told me later they respected me for it.
    onewill likes this.
  6. 0
    Hopefully this thread is helpful for other instructors to read. It's certainly helpful for me to write about it. I'm grateful for the honest feedback I am getting.

    Yes, the night before, we have one patient that we do our prep work and thorough research on as you've described and present a short written clinical worksheet that takes a few hours to prepare. The next morning, one and then two more patients are added on the fly during report.

    Your point is well taken about standing up for myself. I did try that tactfully yet there were some instances that weren't worth standing up for myself - sometimes it is just better to accept the criticism whether or not it feels fair if you have an instructor that seems to be triggered by you.

    The pinnacle of my demise in my third semester was when I was flushing a saline lock to prepare to switch it to a pump infusion. It leaked clear saline under the clear tagederm - I simply couldn't identify it like I would if it had a blockage or if it infiltrated. But it leaked under the arm and gravity caused it to drip under the elbow where I couldn't see it for what it was. I thought it was a good teaching and learning moment as it was a tricky thing to identify for a novice like me who has only read about such a complication rather than see it with my own eyes.
    My instructor pulled me off patient care immediately and to my shock, told me she would need to send me home rather than let me finish my shift. This is when I did look my instructor directly in the eye and I firmly stated, "I don't want to go home, I want to learn - you are my teacher, please teach me. I've been improving, I know I can be successful - why aren't you invested in my success??"
    It was a pretty intense exchange but it saved me from going home; instead, she pulled me off patient care and allowed me to shadow her as she supervised and helped other students (during which time, I saw that one of my peers was about to give a deltoid IM injection into the subcutaneous tissue under the arm - my instructor verbally guided her to the proper anatomy without ill repercussions). That's when I realized that my instructor had a negative personal bias towards me and that my semester was going to be futile - she did not treat the other student like me. I was written up and within two weeks of that I withdrew because her scrutiny became more relentless and it ultimately broke me. I believe I earned her respect...but it was more important for her to be "right". She happened to be adjunct faculty and maybe she was trying to prove herself to the nursing department. To be fair to her judgment, it is true that as I was "breaking", I began making mistakes when she came to supervise me (contaminating tubing and having to replace, contaminating my sterile gloves and having to replace, having a sealed baggie of labeled pt meds drop out of the pt binder I was carrying and get picked up by another nurse, it made me look like a total bobble head that had no business being in nursing, I just sunk). Instructor case was made and I withdrew rather than risk imminent failure. I was an A- student prior to this. I want to learn to be a good nurse. I'm willing to remediate, put in extra hours outside of clinical practicing skills, but it is so much better for handling pressure when you sense that an instructor really wants you to succeed and recognizes what you're doing well or acknowledges your continued improvement.

    I am grateful for having a forum to help me make sense of my educational experience.
  7. 2
    I'm pretty sure the point of nursing school is to learn and be corrected on the mistakes you make (although of course you try to make as few as possible). I have never had a clinical instructor demean me for making mistakes, just compassionately help me. I feel empathy for your situation and hope you never have to meet that instructor again. Your patient load is much higher as a student than mine is too. School is a time to learn not be overwhelmed by the care of many patients, that is not an atmosphere that is conducive to learning. A better way for the instructor to have helped you improve would have been to walk you through what to do in the patients room, then take you aside outside of the room and have you explain what you could have done better or how could have picked up on what was happening to the patient quicker, something along those lines. Good luck to you, I'm sure you'll make a great nurse as you seem very pro-active.
    onewill and Tait like this.
  8. 1
    Quote from onewill
    You rock black sunflower! I am going to save what you've written (I'm new to this and must figure out if I can copy and paste what you've written (do I have you're permission??) so that I can apply it to my typical shift (assignments are NEVER completed by 630 so I would have to adjust accordingly and most night nurses will only report once, not sooner and when they're good and ready -- when they're dealing with a student. Some are more cooperative). You've given me more guidance than I have gotten from my instructor...when we started the third semester, she said - "this is the semester that you need to 'show us what you got' " meaning we were expected to be able to know to do this as you've laid out. Ostensibly within a couple of weeks anyway.
    I have done as you've recommended and then some with my instructor in terms of speaking to her in person, outside of clinical and after clinical to let her know how I best learn and that the pressure I was beginning to feel was starting to become the barrier, not the learning curve itself. I AM going to hang in there and hopefully my reputation with the rest of the instructors for next fall isn't too sullied that they will give me a fresh start to be successful. Thanks so much for your time to offer such a thorough plan!
    Sorry it took me so long to get back to you, I could not find this post. Yes, please save anything that will help you. Do you have brain sheets that you use? I can post mine on here so you can use it if you want.
    onewill likes this.
  9. 0
    Quote from blacksunflower
    Sorry it took me so long to get back to you, I could not find this post. Yes, please save anything that will help you. Do you have brain sheets that you use? I can post mine on here so you can use it if you want.
    Good idea. Here is my sheet, though I swear it fits on one page when I print it off.

    Name:  Brain Sheet.jpg
Views: 1860
Size:  177.7 KB
  10. 0
    You have been very helpful. I have not quite landed on ideal brain sheets. I am definitely grateful to see what you are using. I'm not good at remembering the patient specifics without them - I'm stretched too thin for where I'm at in my development.

    Thanks again!


Top