Student Nurses in ICU for clinical

  1. I am wondering anyone's thoughts/experiences on this issue. Before I start, I just want to say that I am totally for education and totally open to helping anyone learn. I am a new grad myself ..just four months now out in the real world of nursing and will never forget my roots as a student.

    However I was shocked by something that happened today. After morning report I find out that a senior BSN student is working w/ one of my patients. That's fine....I have no problem with this whatsoever. I let the student know that we need to talk over a plan of action as far as who is doing what. This patient is sick, vented, etc etc. Anyhow, the student looks at me and says, oh we do everything. Everything...let's clarify this. I am just off orientation and I know nothing close to everything....ha. Then I find out that there is no teacher around to clarify with me who does what, who is responsible, who is cosigning notes and assessments. I asked other nurses on the unit and they said that this is a totally new thing for the school and that they just do it all together. I let the student know that I want to go through the assessment and documentation together. We did and for the most part everything went smoothly. Then at the end of the shift the student's professor finally comes strolling in, does not even ask who the RN responsible is, takes a peek at the student;s note and then leaves.

    I just am wondering about the legality/responsibility of this. Who is responsible? Is this student practicing under my license? It seems as though it should be made a little clearer as to what is going on with this. I was schooled in a program that even our senior year we had a prof with us, we checked the meds with the prof, we talked about plan of care with the prof, we okayed notes with the professor, the prof was always there.

    I also was schooled in the belief that your time in school was to develop fundamental skills. We observed a day in CCU, MICU, SICU, and ED but we didn't come close to taking on a patient like an assignment. We spent it in med-surg and then of course, OB, Peds, Psych, homecare. I had heard of many other programs allowing students to do ICU classes or specialty programs, however my university was adament that even our senior semesters of a BSN we spend it brushing up on skills. Not ICU skills. The rationale was that you should have the broad basics and then if you want to move onto a specialty that is fine as a GN but the workplace when you graduate or as a job as a PCT while in school is where you get that. I firmly believe in that. It is hard as a new grad with a great orientation process to be there in CCU nevermind as a student taking on assigments.

    I know that I am new so maybe it is just my newness making me nervous if you will. And Ihave no problem answering questions. But I feel like I was doing the job of the absent professor. Any one agree?

    I was thinking about mentioning it to my manager but wanted some insight from you all. Thanks
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    About New CCU RN

    Joined: Sep '02; Posts: 1,039; Likes: 11
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  3. by   caliotter3
    Gee, how familiar this sounds. I did my preceptorship in an ICU during the summer. Our instructor touched bases in the beginning then proceeded to spend the rest of the time getting her summer vacation at her employer's expense. We were totally on our own with our preceptors. Then the instructor appeared in the last week and got "involved". Too late for anyone who encountered problems. I learned a lot because my preceptor took it upon herself to attempt to do her preceptor assignment properly. We also had people do their final semester in the ER and other specialty depts if they could wiggle their way in.

    Yes you were doing the instructor's job, just like my preceptor was doing my instructor's job. But my instructor was a book in herself anyway. I would have learned little or nothing if she had been hovering over me for the time.

    If I were you I would mention it to your manager. Preceptorships are supposed to be structured. This would particularly be imperative in a setting like the ICU. I should have gone in to that environment with some prior prep. Although I was an enthusiastic learner, it was unfair for the nurse precepting me. At least she felt comfortable creating learning situations for me. No thanks to my instructor, I learned more that I ever would have learned otherwise.

    BTW, one of the other nurses in the ICU was hired as a new grad and went through a nine month internship to learn her job. Ideally, this would have been my desire.

    If nothing else, get your supervisor to clarify the legal responsibility questions you have. As a student I checked with my preceptor if I had questions, but you never know what can go wrong and why. Then everyone starts pointing fingers. Good luck with this in the future and please don't let this experience stop you from working with students.
  4. by   Estella
    The last 6-weeks of clinicals I did before graduating with my ADN were in the unit I now work in. The "good" preceptors were the ones who stayed with me the whole time. We assessed together, left earshot and discussed what I would document, what it all meant and I was asked many questions about what to look for, and so forth. We worked as one person and I grew in knowledge. (I swear, I learned more in the first year in the CCU, including just clinicals, than I did the whole three years (part timer) in nursing school!)
    The other preceptors sat at the nurses station and let me attempt to do it all. I never felt good about those clinicals and ended up going to the nurses who helped me the most to ask the questions I should have had the preceptor close by to ask instead.
    Three years later, I still have the "resources" I feel more comfortable with, to ask about things I am still not sure of. There never seems to be an end to things you haven't seen before, and somtimes it's funny when someone with 30+ years experience says, "Hmmmm, doesn't look familiar!"
    Don't be afraid to be with your SN. That future nurse just may end up working with you!
  5. by   mark_LD_RN
    When I was in school we spent a lot of time in ICU,CCU,NICU and neuro ICU . we were expected to do everthing we were assigned to a nurse that the instuctor had evaluated and had reached an agreement with to work with the student. the instructor was always around checking on us. and was available if either I or the nurse mentoring me had a question or a problem. the instructor went behind and signed off on everything I did.
  6. by   New CCU RN
    In response to Estella, I am not by any means afraid to be around an SN...I think you may have misunderstood my posting. These students aren't assigned to a particular RN. They pick a pt and who ever the nurse happens to be responsible for that patient that day is the one that they work with. There are no guidelines for me as far as what the student is and isnt to do. The instructor from the school who is responsible for this student is no where to be found. This isnt some sort of internship by the hospital. It is students here while on clinical time that are brought into the ICU setting and there are no clear definitions of who is responsible. This is where my problem is lying. There was no instructor to sign off on notes/meds or to report to as mark mentioned.
    I asked the student how things normally run and he replied that no one signs off on his notes/meds. Perhaps state law is different, but where I went to school (which is different than where I now work) an instructor had to be present. An instructor employed by the university.
    I have no problem answering questions and being a resource. As I mentioned in my original posting I am a new grad myself. I am just out of orientation. This is all new to me and this is where my concern lies. Why am I taking on the job of the so called professor of the school?

    The set up that Mark describes seems much better. It was organized and there were clear explanations as well as staff nurses that were aware of a student being there before 7am when they walked into morning report.

    Please don't get me wrong. I have no problems with students. I was just one myself.
  7. by   mark_LD_RN
    i would not tolerate such a set up, as that the instructor is just dumping her responsibilities on others. I have seen other instructors in my area do just what you mentioned. I explain my view to the student and tell them to find me the see if we can work it out, if not the student gets no where near my patient on my shift. some students have thought i was just being a _______ but they need to understand it is my license and my patient and i refuse to put either on the line unjustly. I am not the students instructor and should not be expected to do so.
  8. by   Estella
    Hello New CCU RN,

    In our clinicals we were assigned to a nurse, who was directly responsible for the patient care, but allowed us to participate. Our clinical instructor came around once a clinical to check on us, talk with our preceptor, who I guess was really more of a mentor, and if we had done anything unsafe, we would be pulled from the clinical for the day. Since the class was scattered on different floors all over the hospital, an instructor couldn't be with each of us at all times, but was just a page away if we felt we needed her. (A good instance of needing the instructor was when a surgeon walked into a septic patient's room and began an amputation. We had everyone in administration come in for that, as well. Quite a mess!)
    I hope that clears up how our system worked. And, it was our last six weeks of nursing school. Two months later I was in a four week ICU residency at the same hospital along with two experienced RNs and two other new grads.
  9. by   New CCU RN

    I understand what you are saying. Perhaps the set up of your clinicals was better than the way this is run. How it stands now, the student picks a patient. Then whoever the nurse who is responsible for that patient is also responsible for basically instructing that patient.

    My issue is that none of the nurses have been educated with regard to what these students will be doing, who is responsible, who is cosigning notes/meds/assessments. You can try and do everything together, but I generally have another patient so I cannot be watching the student every single minute of the day.
    If the student was assigned to a particular RN who knew the student and was working with them day after day perhaps it would run a little better.

    The instructor never once asked who the nurse was responsible for the patient. The instructor never once introduced herself. This is where I see the problems lying. There was a lack in communication b/n the university's instructor and the nurses who if the time comes would be held responsible in court if something were to happen.

    I am a new nurse myself. I know where these students are coming from, a year ago I was one of them. But when I look back at all I learned in my orientation process and my time in the CCU I find it frightening that students are being brought in without clear definitions of the rules.
  10. by   New CCU RN
    oops, i meant to say instructing the student in my first paragraph
  11. by   Estella
    I agree, the method that is being used in your unit seems much shakier than the method my schoo/hospital used. Another part of the instructor relationship was that all the instructors at my school once worked for or currently worked in the hospital as well as in the school, even if it were only part time or prn. We have a 300 bed hospital, with floating among floors. Getting to know many of the nurses on your shift in the building, or at least knowing the "friend of a friend" isn't unlikely, so if a student messed up, he/she would hear about it.

    Is your CNM aware of the school's policy or how you are feeling? As you know, you worked hard for that license, and need to protect yourself. If you can protect your coworkers along the way, you're a better nurse for it. Perhaps an "Assignment Against Objection" form would be called for. That would allow you to state at the beginning of the shift that there were risks involved with the assignment, including having a student take care of your patient as you take up the care when that sutdent leaves, and legally protect you should anything happen or you would catch a mistake after the student left.

    Just suggesting,
  12. by   BadBird
    I love to have student around, you can teach and you can learn. If I was that student I would seriously consider another school, your instructor should always be in the unit on hand to act as a resource person, answer questions, check on your assessment skills etc.. I guess that is why I have noticed that the new nurses coming out just aren't as prepared, they don't know it because there is no instructor to teach them, how sad for the patients.
  13. by   whipping girl in 07
    In our ICU clinicals in school, there was one nurse that was responsible for the students and didn't take a patient assignment. Then each of the students were assigned to a nurse for the day and helped as they could with the patient. We did not do any documentation other than VS and the checklist on the nurses notes, which was reviewed by the nurse who was also caring for the patients.

    I find it scary that a student would walk into ICU and say we do EVERYTHING. As a graduate nurse, I didn't do everything until halfway through my orientation, and I only did the stuff I knew how to do.

    I also did an internship for three weeks during nursing school, and it was a little different. The same nurse who was responsible for students before precepted one student at a time but it was only for one day, as we floated all over the hospital and did time in a cardiology clinic and surgery. Again, the nurse did everything WITH the student.

    I work now at a different hospital than the one I did my ICU clinicals at, and we do things a little differently with students. They are matched with a nurse preceptor for the day and do as much as they can with the nurse preceptor. They do NOT do everything themselves. And the students aren't matched with a relatively inexperienced nurse; the same preceptors who train new nurses are the ones who work with the students. It seems to work quite well.

    As for licensing, you are not responsible for what the student is doing; she is not working under your license. But you are responsible for what happens to the patient, so the student needs to be watched closely and double checked. I could not believe when I was in nursing school the number of nurses who just let me do it, giving no thought to the fact that I COULD harm their patients if I didn't know what I was doing. I know that I could not be that lenient with students if I was dealing with them today.
  14. by   sharann
    NewCCU RN,
    I am appalled (appauled?) at that nitwit RN instructor. First of all, the students are there as a privelege, not a right to the school. Hospitals like to hire those who did some clinicals there...less difficult orientation they feel. Anyhow, you are the nurse and have the right to call the shots. The instructor needs to be accesible by beeper or phone at ALL TIMES the student is on the premesis. Also, the student follows you, not vice-versa. You are barely out of the nest yourself as you have mentioned, and I fully believe this is unfair and unsafe practice for the hospital and you. Good luck. It's good that you remember that feeling of being a student. I hope to never forget.