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

[greenbeanio]

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?

[hiddencatRN, BSN, RN]

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]

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]

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]

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.

[MseagleusaRN,BSN,MSN]

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.

[CBsMommy]

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!

[JBMmom, MSN, NP]

I certainly am sorry that you're feeling badly about your experience. I hope that you can find a positive in the attitude that your clinical instructor has taken. As she said- your safety isn't an issue, but speed apparently is. If you were a total mess, you wouldn't be passing no matter what, so you're good there, to an extent. However, if she said that you're not where a third semester student should be, there is a possibility that you will have to repeat the semester. I'm sure that would sound like an awful outcome at this point in your career, however, maybe another semester to gain more experience would be very helpful for increasing your speed and comfort. Otherwise, the suggestion to get some work as an aide or PCT would also probably get you some very good experience. You're obviously very conscientious about your patient care, and that's admirable. However, by the time students finish nursing school, they do need to be prepared to administer safe, competent care to four or more patients, and complete that care in the course of a shift. I hope that you find a good system, and you need to make sure that you're confident in your own abilities- then maybe some of the questions won't cause you a time issue. Best of luck.

[jjjoy, LPN]

I hear you OP. Some programs do not accomodate those of us who may need more clinical time to "get up to speed" than some others. And the reality is that many work places also expect newbies to "get up to speed" pretty darn quickly.

I don't believe that just because a student or nurse may take a bit longer to comfortably learn to speed up routine care that that means that they just don't have what it takes and should do something else.

But many programs and employers do not allow much time for a steep learning curve, so for the 'slower' student/nurse to succeed, they need to find ways to support their learning style - such as carefully choosing a nursing program and positions with strong clinical training and supervision (as opposed to programs and positions that more or less just give you the opportunity to sink or swim).

Getting a lot of related experience can also help this type of learner so that they aren't trying to master everything all at once. Experience as a nursing assistant can help nail down basic care. Experience as a unit clerk can help to learn common orders and improve interdisciplinary communication. Experience as a EMT may offer opportunities to hone assessment skills and reinforce how to handle emergent issue (which felt incredibly glossed over in my nursing program).

If you do end up needing to re-take this course, it could be a blessing if it allows you the opportunity to build your skills. Then the next time you go through clinicals, you'd be able to learn that much more because you'd have freed up a lot of your learning energies.