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

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    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 care, I am "behind" schedule and need a better system of approach to my shift responsibilities. One barrier is that I am experiencing nerves and anxiety symptoms that I haven't had before because of the demeaning methods of my clinical instructor. My heart starts pounding as soon as I see her. I want to learn, I'm eager to become a good nurse. I spend more hours in campus lab than anyone else to master skills. However, I believe my weakness is an organized execution of my duties. We have been told that this is the semester is the semester to "show them what we got" meaning we should somehow have this organized approach to multi-tasking down already. Some of us do - like the ones who were CNA's for years. That Isn't me. And I don't seem to be learning how to develop this when I am barraged with criticism rather than offered support and true teaching. I wish there was a blue print or flow chart that teaches folks like me how to approach prioritization of care in an atmosphere of multiple priorities; I'm not getting it through mentorship - I just feel like I've been dumped on the floor and expected to perform beyond my current capabilities, under pressure, and without a road map. I was told by my advisor that some students like myself just hit a wall in this semester and can't continue. I've worked too hard! I'm a good critical thinker! Does anyone have any suggestions for remediation? Books, videos, etc. that address this and might help me help myself?
    Thanks so much. I know I can do this with the right help !
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  3. 20 Comments so far...

  4. 4
    "Dumped on the floor without a road map" this rings so true to me. Even as a seasoned nurse now, I clearly remember those days from school and my first year or two.

    In school I was someone who had to have multiple highlighters, draw pictures of concepts, and see patient conditions in action in the hospital setting to understand them.

    When I started nursing I was determined to create a tasking system. Something I carried in my mind was "this patient is a person" so my first task was to make them feel like that. I quickly found that you need to set up a rapport, within five minutes or so, with your patients. I would come in, ask how they were, tell them I was a student and I would be taking care of them all day and if they needed anything to call me and I would get it taken care of. During this time I was assessing. Color, breathing, touch the feet for pulses, look over the room for proximity of items, O2 tubing, IV lines etc. This portion gets more and more natural as you go on in your career.

    The point here is combining tasks. Chat and assess. Ask about pain and immediate needs. Then let them know you have a few others to see and will be back shortly with the next task (meds, bath, etc). Think about it as a waitress. You stop by, ask the table how they are, assess drinks and needs, address quick questions about the menu, and then let them know you will be back in a few minutes.

    Do this with all of your patients, spending 5-10 minutes per room and you have a rapport, a commitment, and a handful of early information.

    Now look at what is next. Do you need to get drinks (medications) or is there 30 minutes to do your assessments? Let's say one patient needs meds before 8 and it is 7:55, then rest have 9 am meds. Grab your stethoscope and the early med and head in. Do your head to toe assessment, reassess needs (how is your meal), and then head to the med room for the next priority patient. If someone calls out in the middle for pain meds, finish your assessment, then go deal with the pain med. Stop into the room of the patient with pain and let them know you are going to get their meds, while assessing their pain level so you know what to bring in.

    My jist here is nursing/clinicals is about combining steps. Just like when you do a dressing change you don't want to run out of the room for each supply individually. You assess the wound, look at what supplies were used before, then let your patient know you are going to gather your stuff (get the salad, appetizer).

    Also creating a one page sheet where you can track the more tasky aspects, med times, glucose checks, is very helpful. Have all your patients on one page so you can quickly see where you need to move to next. Look at what the nurses on your unit use for this "brain sheet" and then create one entirely your own. Make sure it works for you. I used to have a grid for each patient with times and then I would highlight times when meds were due. That was a small part of it, but for me it gave me a fast visual cue as to where I needed to be next.

    As far as your instructor, don't take his/her issues personally. Instructors are overwhelmed with students who are entering a demanding field with little experience and confidence. I had an instructor that failed a student because she broke down at the bedside of a patient with stress. This gal is a nurse now and all is well. I learned that day that I had to just move on and show I could handle. Prior to this I had been flunked by a clinical instructor for not being focused enough. It held me back an entire semester, however I went on to mentor the next class and do much better, learning more, because I had created a better environment in my life to support being able to focus on school (working during school and dealing with kicking a roommate out is taxing).

    If your instructors aren't giving you good feedback, look to other students. Who in your class appears to be moving smoothly through clinicals Ask them what their system is. Ask to see their organizational style. Perhaps in the end you will find, like me, they did better in clinical than they did in class, and there can be some kind of educational swap. Your brain sheet for my ability to take the tests/learn the info.

    Hopefully this makes sense. I was a waitress all through school and felt it taught me how to manage clinicals the same way.

    Best of luck,

    Tait
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    Wow, that is great feedback! The most reassuring thing you shared with me is the experiences of "near" failures that ultimately turned into successful nursing careers like yours and your classmate. I have just withdrawn from my third semester not because I am not "smart" enough but because my confidence was shot and by the end, I was beginning to make silly mistakes which compounded the criticism from my instructor who already had me in the cross hairs. Again, a mental focus issue. So like you, I am now set back a semester but am trying not to lose hope and to believe that just because I have hit this wall, I can still go on and be a good nurse. I know I'm salvageable !

    I welcome any other feedback and additional suggestions from others who have walked the path or from other clinical instructors. Thank you !
  6. 2
    I am a clinical instructor. Where are you struggling specifically? What are you not getting done? How many patients do you have?

    Very basic, but our flow tends to be:
    -Report (you should be getting an idea from the RN about what the patient's needs are and plans for the day)
    -Introduce yourself to patient and explain your role
    -Assessment and vitals
    -Helping patients with breakfast if needed
    -Bathing/Hygiene
    -Medications (bathing and medications are often switched with one another depending on the flow of the day)
    -After medications we can focus on other tasks that may need to be done (dressing changes, trach care, etc.)

    I strongly encourage students to get in the patient's room ASAP. I find many "don't want to wake the patient" or find other reasons to delay getting in the room. This will get you behind. They must have vitals and assessments done before medications. I encourage this to be charted ASAP as well. I round early to find out the plan for each student and patient. After medications, I round again and can help students with other tasks.

    However, I am very approachable and not the type of instructor you are describing. I have had disorganized students. I find it is a combination of delaying the start of work, saving all charting until the end, and talking too much (and often the patients LOVE this, but you have to strike a balance).

    If you are taking a semester off, have you considered working as a CNA or tech?
    Last edit by daisy78 on Apr 1, '13 : Reason: spelling
    onewill and Altra like this.
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    Yes, I have decided to find a job as a CNA or tech. I think it would be good for me to get used to the hustle of a caseload. As for my clinical experience, we work with primary nurses that we depend upon to get meds out of a locked pixus for us...so I find that a fair amount of the time, this impaired my flow of care if they had other priorities with their other patients. AFter report, I would wait for a computer to look up labs, admit. and hx, and care plan and plan it out on my brains. Daily weights, I/O's, q4h pain assessments, finding my primary nurse to get me patient meds, turning pts, glucose, insulin on pts due at the same time, etc. Bed baths and trash changes are done by auxiliary staff; however toileting/changing is our duty if we see it first. I don't spend much time talking but I did find that charting on a new system I wasn't used to was pretty slow going. Also, getting used to a new hospital with new supply rooms and such also added on extra time so the beginning of my semester I wasn't a "hustler". The policy for giving meds is one hour before or one hour after the due time; however, I found that my clinical instructor was harsh with me if they were 15 minutes after the due time...so I felt pressured there, especially in a new med room and calculating and preparing IV push meds for the first time this semester. When she pressured me, I once made an incorrect calculation. I felt I wasnt safe at the speed I was being pressured to achieve. New IV pumps...I needed help the first couple of times to operate, then after that I could do on my own but I wasn't quick with it; if I tried to go quickly, I would catch myself about to make a mistake (and my instructor was good at seeing the imminent mishap a second before I would!) and this all contributed to my instructor's sense that I was incompetent without her presence. Very demoralizing and it mentally got to me so that my natural learning became impeded by my fear.
    Anyway, I do feel like I could have benefited and still can benefit from advice on how to tackle a caseload of 3 the first half of the semester, work up to 4 by the end of the semester and be ready for five for the final semester. I had 7 weeks under my belt this third semester which added up to 11 clinical days total so at least I will have that as I start fresh at the beginning of the same semester again...and definitely with a different clinical instructor that I mesh better with. I think my biggest challenge is seeing the whole picture of what each pt needs at what time and who to see and what to do first especially when they have things due at the same time. I am told that this takes experience to perfect; however, I was feeling pressure to achieve a competency level too quickly to be safe.

    I have worked so hard to get this far that to think I could be weeded out because I'm not building that focus and organization as quickly as I am expected to (I DO believe I can get there) often wakes me up in the middle of the night. Like I said, Hopefully CNA experience will get me used to the hustle of a caseload.

    Thanks so much for replying to me.
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    I definitely agree that it is difficult to manage time flow when you have to wait for someone else, so figure that will get easier when you are on your own practicing. They have you taking five in nursing school? Wow, the most I ever had was two in my last clinicals. It wasn't until I was hired that I worked up to a full load.

    There is discussion in a few new grad programs now that having a NG take five patients right away, however only given them one task to complete, such as doing all the assessments, is a better way of ramping up the responsibility.

    When I had to repeat my management clinical I did much better with my second instructor. The way he described it was "Your last instructor set the bar up here and made you jump, I set the bar down her and help you reach higher and higher each time." He didn't mean it to degrade the previous instructor, only to show that different teaching styles work for different people, and he was spot on with me.
    onewill likes this.
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    Well, we don't get 5 until we get into our fourth semester of the ADN program. In the first half of my 3rd semester, I was going from 2 to 3 patients at the time that I withdrew. It wasn't just the number of patients, I felt it was the deadlines throughout the shift that I was pressured to meet (in a safe manner). You make some good points and now I don't feel so self-denigrating about not meeting a bar that was set too high too soon for me. However, it will be the same way when I return: start at 2 at the beginning of the semester, work up to three then four...but hopefully I will get an instructor that is more like your second one.

    I am interested in what other instructors might have to say about the expectation of working up to four for the third semester. Not having autonomy with retrieving meds and being unfamiliar with where supplies are on the different floors we get assigned to (we get a new floor every week or so) can sure hamper efficiency. Counting all actual clinical days in the semester, it amounts to 18 days on the floors.
    Thanks for your response, Tait.
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    Wait...so four patients and a new floor? To me these sounds like ridiculous expectations. I am curious as to what others would say as well. Maybe we should start a poll somewhere...
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    I think the number of patients is dependent on how your clinical is set up with the hospital. I can never give students that many patients. (8 students x 4 patients = 32 patients) I cannot manage that many patients safely and the hospital I am in, the staff nurses do not "precept" or "mentor" the students. It is all on me to get meds done with my students. So that would not be safe. I would love if by the end of the semester, I could have students mentoring with a nurse and a full-assignment. But only if the nurse was truly mentoring. Sadly, I have yet to encounter a clinical situation where staff nurses were willing to do that.

    I think you have unfortunately encountered a "perfect storm" of an intense nursing instructor, too many patients, and not enough support from the primary nurse (and I understand, they are very busy). Without knowing you and seeing you in action, it is hard to fully advise. It also sounds as though you do not get time to research your patients. We come in 45 minutes early so that students can access the computer and get their information.

    Are you able to pull meds early and hold on to them (does your instructor give meds with you or the staff nurse?)?
    Tait likes this.


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