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Does anybody ever fail clinical because of time management? ethical question

Posted

Specializes in mental health. Has 3 years experience.

Does anybody ever fail clinical because of time management? Or am I the only one?

Med-Surg clinical has me teetering on the brink. I have a clinical instructor who has been riding me all semester, convinced that I can't do it and saying things like "You're just not where you should be at this point in the semester".

My last clinical day one of my patients was very obese, SOB, exhausted and pretty immobile. Everything with him was in slow-mo. He had frequent diarrhea, so that didn't help. The bed bath took forever because he couldn't really turn, and because he was too tired to do anything for himself - even wipe his face. It even took him a long time to respond to anything I said.

I was well aware that I was getting late, but I didn't feel like I should leave him with stuff still undone. So that made me late for documentation, which made me late for post-conference, which I got in trouble for.

I tried to explain that when it came to a choice between patient care and documentation I felt I had to choose to do the patient care first, and then when it came to a choice between documentation and post-conference that I had to do documentation first (she has made it very clear we are not to leave the floor without completing documentation - no going down for post conference and then going back for documentation). But the response I got was "you shouldn't put yourself in a situation where you have to choose".

The only way I could have gotten done on time was to cut corners either on patient care or on documentation, which would be really hard for me to do. I just never do things like that. Although I have seen the experienced nurses make decisions like that. Honestly I have never even seen any of them doing a bed bath. (Sometimes there's one CNA on the floor, sometimes none - usually it's all up to the RNs.)

Now I have exactly two more clinical days in which to prove myself or else I fail, bringing down my entire GPA (I have an A- average right now), which in turn affects grad school in the future. The other students in my clinical group have asked if there's any way in which they can help and I have said that if they are done with everything and have any extra time to check in with me and see if they can help out with bedmaking or a bedbath or ambulation or something like that. But now I'm thinking that if my clinical instructor sees any of them helping me then that's going to count against me too.

So I'm left with the option of cutting out the less crucial aspects of patient care like those things, and cutting out detailed notes in my documentation and just hitting the "use previous values" button (and then checking them over) instead of filling in every single question individually. It just seems so wrong. What would you do in this situation?

I am sorry to say this, but you must graduate from nursing school, so that means you need to make the decision to do whatever it takes to make that come about. Your post reminds me of a conversation I had with one of my classmates who was doing very well. She told me in no uncertain terms that she told the instructors what they wanted to hear about everything. She tailored her documents and input to reflect what was expected, and not necessarily what was reality. You sound as if you need to cut the corners and speed things up like you suggest. Your task is to get through this for you. You can tend to business the way it should be on the job, once you have graduated.

OrthoFNP

Specializes in Orthopedics.

I am so sorry to hear that. That sounds like my worst nightmare. I have an awesome clinical instructor. She actually encouraged all of us to team up. In her opinion nursing is teamwork. We are only first semester though. I guess the only thing you could skimp on would be patient care. I am sorry you are in that poistion. It seems unfair.

melmarie23, MSN, RN

Specializes in L&D/Maternity nursing.

Nursing is about teamwork. I'd take up your classmates up on their offer to help. Dont use them a a crutch, but if you are stil finding yourself behind, let them help. If your instructor has beef with that, let them take it up with your classmates.

Its absurd that you are getting in trouble/about to fail because of this. You havent made a med error or inuried a patient in any way. You havent done anything wrong. And I disagree with a previous poster-dont cut corners just to get by. Thats where accidents happen.

If your instructor is still threatening to fail you over this, you then need to think about going to the department head or dean.

Jolie, BSN

Specializes in Maternal - Child Health. Has 35 years experience.

How did you comunicate with your instructor, cooperating nurse and classmates during the clinical day?

Did you let these colleagues know that you were falling behind and in need of help? Did you properly prioritize your patient's needs and consider those that may have been given lower priority and delegated to the nursing assistant or classmates?

Every reasonable nursing instructor realizes that there are uncontrollable factors which require extra time (fatigued patient, diarrhea, extreme size). Perhaps she was testing your ability to address these challenges and problem solve.

I would suggest you schedule a conference with your insturctor prior to the next clinical session.

Aurora77

Specializes in Med Surg. Has 4 years experience.

You sound as if you need to cut the corners and speed things up like you suggest. Your task is to get through this for you. You can tend to business the way it should be on the job, once you have graduated.

This is absolutely insane. Not you, Caliotter3, but this mindset. I'm getting a similar weird vibe from my NS experience, so I'm a bit sensative to things like this. Are they intentionally teaching the OP that cutting corners is the way to go? Instead of offering constructive criticism about ways she can speed up what she's doing, the way to get through is to cut corners on something. How does this make any sense at all? They way we behave in school will be reflected in our professional lives. If the school is teaching us to cut corners now, they want us to cut corners as nurses. This can't be the way to resolve this issue.

llg, PhD, RN

Specializes in Nursing Professional Development. Has 44 years experience.

I notice that the OP and others automatically assume that "speeding things up" requires that corners be cut that compromise the quality of the care. That's a wrong assumption as it is not always true. Some of the best (and most conscience and detailed) nurses I know are also the fastest at getting their tasks done.

The goal is to me organized and smooth in your practice so that you can accomplish the same number of tasks in less time -- NOT to eliminate elements of good care.

New nurses (and students) often take longer to perform a task than a veteran as they are hesitant in their practice, pause to double- and triple-check things, etc. Experienced nurses are more efficient as they are organized in their approach and confident and quick in their performance. They gather their gather their supplies ahead of time, they move efficiently from one task to another without stopping to think, triple-check, look for supplies, pause to review, etc. In other words, they get the same tasks done in less time.

My advice is to review practice and identify those time when you paused to think, hesitated, triple-checked, etc. and/or did anything that added a few minutes here and there to your time and/or were less time-efficient than they might have been. That's hard to do. As a student, you are working hard and it probably feels like you are going as fast as you can. But I'll bet a seasoned nurse could wipe that bottom faster, change that linen in less time, or whatever. Also, experienced nurses learn to do 2 or 3 things at once (e.g. pick up the linen you need on your way to do something else rather than waiting and then having to make a special trip, etc.)

Yes, use your teammates as appropriate ... but be careful and do so very judiciously. Your instructor wants to see that you can accomplish the care required in the allotted amount of time. As a staff nurse, you'll have to squeeze in a lot more things into your day -- and you need to show that you can work quickly in addition to doing it correctly.

Don't make the mistake of assuming that efficient care is not good care. The best care is cost effective -- that means both effective (good) and efficient (quick).

... and yes, students often fail because they can't keep up the pace required for clinical practice ... and the inability to keep up with the needs of multiple patients is one of the most common reasons that new graduates fail to succeed in their first jobs. Time management is a VERY important skill to learn.

melmarie23, MSN, RN

Specializes in L&D/Maternity nursing.

doing skills efficiently is something that comes with practice. Right now, the OP is there to learn, and part of that is executing tasks correctly. If the OP is a bit slow right now, then she is a bit slow. I can understand wanting to fail the OP because they making grave mistakes, but falling a bit behind?

Even the best of nurses fall behind on some days. What the OP's instructor should be doing is turning this into an opportunity to learn and hey, maybe even give the OP pointers on how to become more efficient in completing their tasks.

and likewise, OP, you might want to seek your instructor's or another professors counsel on ways in which you can improve.

OrthoFNP

Specializes in Orthopedics.

melmarie23,

I did not mean cut corners with assessment or with anything dealing with patient's health concerns. I simply meant to try and do things like linen changes and bed baths more quickly by utilizing other students assistance. I guess I was not clear. I would never suggest a person cut corners on essential patient care. I am a huge advocate of teamwork as I suggested, this is a way to reduce time. Reducing time on care doesn't neccesarily mean making the care less safe. Why is one person assigned to give a bed bath and linen change to an immobile obese person anyway? That is definitely a situation that calls for more than one person. Hmmmm...Like I said before teamwork. ;)

greenbeanio

Specializes in mental health. Has 3 years experience.

Melmarie, even my clinical instructor said I'm "very safe - so much so that it slows you down. But there have not been any concerns about safety." :)

But she does think I'm still too hesitant, still wanting my work double-checked, still not certain about what I'm seeing or hearing. I think she feels like I'm acting like a first semester student, not a 3rd semester students. She says "you shouldn't need to be asking those questions by now".

For instance, this week I had this patient who I had seen the previous week and her lungs had been clear. But a week later, I was heard crackles in her lower lobes and rt. middle. I impressed upon her the need to walk and to deep breathe and use her incentive spirometer. She took me seriously and really started making an effort. The next day she told me proudly how much she had done. But when I checked her lungs again it seemed like the crackles had gotten worse overnight and were moving up her back. I wasn't sure whether it was really in her upper lobes or whether it was somehow "referred sound". So I asked the staff nurse who had that patient if she could take a listen to the pt's lung sounds. She listened and said no, she didn't think it was in the upper lobes. (Although I still really think it was.)

When my instructor was riding me for needing to ask questions I brought this up and asked if that had been inappropriate and she said yes, because I'm supposed to know by now where the upper lobes are. "That's A&P - you should know that! And we just went over the respiratory system in class. You're not being able to take what you learn in class and apply it in the clinical context." And I'm thinking well, diagrams in books just don't always translate when it comes to the incredible variation in people's bodies.

Later, I was puzzling over what was going on with my patient and her lungs, and I thought about the fact that she also now had edema in her legs and feet, and how she had been saying she'd gotten so fat and bloated in the hospital which had puzzled me since she had been NPO since her surgery 8 days ago... So I checked her weight and found a weight gain of over 60 lbs in 8 days! You should have seen the nurse's expression of disbelief when I told her this, but it was true. So then I did feel somewhat justified in my concern over the rapid change in the condition of pt's lungs, from one day to the next.

But I guess she would still say I shouldn't have needed to ask the nurse to verify my assessment. It's just that I tend to err on the side of caution. And yes, that does slow me down.

FA2NS, I would LOVE to have a clinical instructor who valued teamwork instead of only evaluating my ability to function fast and independently! Lucky you!

caliotter3, Yes, you are right. It really helped to see it written out like that: "you must graduate from nursing school, so that means you need to make the decision to do whatever it takes to make that come about". Some of my friends in nursing school have also been telling me that if I never graduate and never become a nurse the world will be the poorer for it! And that many patients would benefit from having me as a nurse than the 4 who would suffer by not having thorough bed-baths and bed changes for one day!

In fact that has been one of the amazing things that has come out of this whole thing - the feedback I'm getting from other nursing friends, not all of whom are even close friends of mine. It's almost embarrassing, having these positive qualities pointed out to me, but it's reaffirming my conviction that I can do this!

Sorry this has been such a novel. It's just been roiling around inside of me. But now I feel clearer - and I think I can go off and study for the 2 exams I have in the next 2 days!

greenbeanio

Specializes in mental health. Has 3 years experience.

Jolie, no, I really didn't think of asking for help. I guess because she has seen me as the weak student all semester and she has actually told people not to help me because I need to become more independent. So I just put one foot in front of the other and worked my way down my work list.

llg, thank you for your post. I absolutely agree that a seasoned nurse would have done it all way faster than me - in half the time or less. But how do I get to practice enough so that I can get faster? I feel like I need more practice as well as more instruction. This is why I have been asking my clinical instructor to let me shadow a nurse for at least a couple of days or even hours, so I can see how different nurses organize and prioritize. But she keeps saying I need to figure out what works for me. But how do I just "figure it out"?

You know what? I'm going to see if they'll let me come and shadow on my own time.

DolceVita, BSN, RN

Specializes in IMCU. Has 10 years experience.

Gosh I am sorry it sounds like a bit of a hard time.

This is why I love my instructor.

Melmarie, even my clinical instructor said I'm "very safe - so much so that it slows you down. But there have not been any concerns about safety." :)

For instance, this week I had this patient who I had seen the previous week and her lungs had been clear...But when I checked her lungs again it seemed like the crackles had gotten worse overnight and were moving up her back. I wasn't sure whether it was really in her upper lobes or whether it was somehow "referred sound". So I asked the staff nurse who had that patient if she could take a listen to the pt's lung sounds. She listened and said no, she didn't think it was in the upper lobes. (Although I still really think it was.)

...

Later, I was puzzling over what was going on with my patient and her lungs, and I thought about the fact that she also now had edema in her legs and feet, and how she had been saying she'd gotten so fat and bloated in the hospital which had puzzled me since she had been NPO since her surgery 8 days ago... So I checked her weight and found a weight gain of over 60 lbs in 8 days! You should have seen the nurse's expression of disbelief when I told her this, but it was true. So then I did feel somewhat justified in my concern over the rapid change in the condition of pt's lungs, from one day to the next.

I think this might be an example of what llg is referring to about efficiency. Had you checked the pt's lungs, then weighed her, *then* gone to the nurse, your instructor might not have found that to be a bad course of action. I know hindsight is 20/20, but when you do need verification from a nurse or the instructor, what other data can you bring to them that support your assessment?

Also, your statement about being so safe that you are slowed down...I think that is probably more the issue than taking care of the obese patient. Yes, you don't want to make any errors, but it sounds like your instructor wants you to be at a point where you are comfortable and confident enough not to need so much double checking.

greenbeanio

Specializes in mental health. Has 3 years experience.

I'd love to be at that point too - but how do I get there? I figured the more experienced I get the faster and more certain I'll get, so that's what I've been asking for but not getting. Any other ideas?

OrthoFNP

Specializes in Orthopedics.

You sre doing great in my humble opinion. We are not nurses yet and asking qurstions to verify findings is what we are supposed to be doing I thought. I see things the same way you do. I would do the same exact things asking etc. I am very unsure about lung sounds etc. It makes me VERY nervous...

llg, PhD, RN

Specializes in Nursing Professional Development. Has 44 years experience.

I'd love to be at that point too - but how do I get there? I figured the more experienced I get the faster and more certain I'll get, so that's what I've been asking for but not getting. Any other ideas?

There is no "magic solution" or "secret method." You just have to be willing to take a few risks -- not foolish ones, but risks that you have prepared yourself for. Being responsible for the well-being of someone involves a little nervousness. In some ways, it is as much of a personality thing than it is a skill thing. Some people respond to that nervousness by slowing down and being extra careful. Others take a deep breath and "go for it" -- doing what they think is best without pausing or slowing down to triple-check things or hesitating. You have to be a bit of a risk taker to be a nurse. It might help you to think through how you feel about taking risks and taking on the responsibility that nursing brings.

Notice how the experienced nurses do things -- particularly the more simple, routine tasks. How much time do they take with those things than you do?

Identify those things that are unlikely to hurt the patient much and simply jump in and do them more quickly. Things in this category include things like your basic hygiene and routine assessments that you have done many times before. You are unlikely to make significant mistakes with those things, so you should be able to speed it up a bit. The more critical things, such as medications, you need to be a little more careful with.

As you said in a previous post, you are no longer a 1st semester student. This is your 3rd semester. There should be a whole lot of basic tasks that you have done many, many times now. Those are the things that you should be able to do quickly, confidently, and competently. Make a list of those things that you did in your first semester -- and that should be 2nd nature by now. Go to clinical prepared to speed those things up a bit.

Not fail, but the student needs to tighten up on the assignments and manage her patients. By the end of the second year, a nursing student should be able to manage two patients. One complicated, one simple. By the end of the third year, three patients etc. Point deduction should be considered for tardiness, late treatments, late medications, poor and untimely documentation. These are reasonable expectations for a nursing student.

OP, if you want more practice, I would suggest finding a job as a PCT or CNA somewhere. If it's the basic tasks that you are having a problem with, I would find a job in a nursing home where you would get a TON of practice with these skills and meet some fantastic CNAs who have probably been doing their job for years that could give you some pointers about how they manage their days!

I agree with the poster that said that it was all about organization. I just finished my third semester and have my day planned out before I even hit the floor. I've been doing my clinical days the exact same way since the beginning of the second semester. It's easier to deal with "curve balls" thrown your way if you have a plan of attack, so to speak.

How long are your clinical days? Hours you are working? How do you organize your day? Maybe you can ask your clinical instructor how he/she would organize their day. Acknowledge that you might have a little time management issue and accept the help. It doesn't mean that you are a "bad student" but everyone can find ways in which to better themselves. Do it now, while you are a student.

Finally, I really hope that you were not trying to move an obese patient without help. If the patient was so exhausted that he was not able to wipe his face, it doesn't sound like the patient was able to help you move him. Don't hurt yourself before you even begin.

Good luck. It sounds like you really want to succeed. I hope that you can work it out to where you can!