Failed preceptorship

[Spurse32]

So I failed out of my last class, my senior practicum, preceptorship. I'm just looking for a little perspective. I'm gonna try and make it brief as possible so bare with me.

I love psych but also like ER and all the medical side of things. I decided to go for psych because I thought I would enjoy it over med-surg. I discussed this with my clinical director and we decided on gero psych. I ended up an inpatient, drug rehab facility. It's a nice facility that incoporates detox and a longer stay unit. I thought what the hell, It's not my first choice but I'll make the best of it.

My first day was very slow. They couldn't get me in the computer system to chart or give meds so all I did was take BP and HR. I was getting along good with the patients but I knew RIGHT away that choosing psych to start was a mistake. Weirdly enough, one of the first patient interactions was someone with pneumonia. Right then, I knew I needed the medical background first but I didn't mention this this to anyone and I carried on. I had only 7 shifts left and I wanted to stick it out.

Finally I got to pass meds. I think the second person I gave meds to had like 13 meds. I immediately felt overwhelmed. I got his vitals first. I saw that he was taking dig so my preceptor said make sure to get an apical pulse. I went to the med room first though to start collecting his meds. While I was in there she said get an apical pulse. I thought she was just reminding me but I think she meant like NOW. Finally she goes, "for the third time, get an apical pulse". I said ok...do you want me to get go do it now? She said no, just finish getting the pills. I got his apical pulse before giving the dig. It was 85. I gave him all his meds. This was one incident that was brought up at evaluation. I would have known next time to check the apical BEFORE grabbing the pill but I didn't get another chance to do that persons meds.

Another incident was someone who had cirrhosis and major fluid overload but no respiratory symptoms like crackles or SOB. My preceptor was doing his meds and asked me to get a O2 sat for him. I put it on him and it read 91% so I told her. She said to leave it on longer and have him take a deep breathe and sit down. It went up to like 93, 94. I was supposed to know to leave it on longer. But again, didn't get a chance to do O2 on a critical patient. Or critical for that unit I should say.

My preceptor wasn't around and a patient came up complaining of anxiety. I looked at his chart and gave him PRN 1mg ativan. I told my preceptor what I did when she got back. She asked me if I got his BP first. I didn't. I forgot or was thinking that we took his morning vitals and that was all we needed. I said, damn, I was just about to and I didnt. I told her I would check it next time I saw him, just to be safe. She said don't bother it's over, now you know, you won't do it again. That was the first and last PRN narc I gave.

I asked her sometime last week for feedback. She said I was good with groups, good with the patients, a big talker. Nothing negative.

But last night, the second to last of my shifts at the end of my shift, I got my "mid-term eval". She started going over some incidents but that I could do better on my last shift but that she would never do anything to jeopardize me not graduating. She mentioned those previous incidents but also something about not taking the pulse ox on the side of a BP cuff inflating. She said it can cut off circulation and change the reading. I said ok. She also said I have poor body language and no "eagerness" to do vitals when a patient needs it.

On my last shift today, right when I was supposed to shine and improve, I messed up big. Preceptor told me to count pills for a discharge and note it. She put the meds down and said go fast b/c we were busy with discharges. Well she put the meds right down next to an insulin vial someone left out, probably from night shift. Before though, the patient had lisinopril that wasn't on the sheet that listed his meds. I asked my nurse about it and she said it was added later, go ahead and add it. Well, I applied the same logic to the insulin vial. The patient doesn't take insulin. I gave her the whole bag and said I was done. She said...what's this insulin doin in here?? Opps. I still can't believe I did that. I'm sure there were other mistakes that I made but that is what was brought up. I don't think I did any other "major" mistakes.

My evaluation today was that I'm not safe. A lot of the nurses don't want to work with me because of safety, I have poor critical thinking, poor assessment, and I dont' apply knowledge that I know. I'm probably going to appeal but I think I'm going to lose. I did a lot of things good but the workflow is so slow, I don't think there was enough to prove myself, only enough to make mistakes, which are my fault, I know. I was so bored there. It was supposed to be my preceptorship and me "being the nurse" but it just wasn't like that. On average, I probably did about 1 or 2 hours of actual work, if that. The rest was sitting around doing nothing or walking around aimlessly. And trust me, there was NOTHING to do.

I feel like I was set up to fail for sure. Why wasn't this stuff brought up to me earlier? But I also get soo anxious, especially if I make mistakes. I live in them. If I don't do good at first, I sometimes get anxiety to the point where I can't think at all. It's like I can feel my IQ just plummet. So here I am, wondering where the hell to go from here.

[Jolie, BSN]

I formed my opinion when I read the second to last paragraph of your post, "but the workflow is so slow, I don't think there was enough to prove myself, only enough to make mistakes, which are my fault, I know. I was so bored there. It was supposed to be my preceptorship and me "being the nurse" but it just wasn't like that. On average, I probably did about 1 or 2 hours of actual work, if that. The rest was sitting around doing nothing or walking around aimlessly. And trust me, there was NOTHING to do.

I feel like I was set up to fail for sure. Why wasn't this stuff brought up to me earlier? But I also get soo anxious, especially if I make mistakes. I live in them. If I don't do good at first, I sometimes get anxiety to the point where I can't think at all. It's like I can feel my IQ just plummet. So here I am, wondering where the hell to go from here."

Where should you go from here? I suggest that you go back to the unit and apologize for your laziness and poor attitude during your preceptorship. Then meet with your academic advisor and find out if you will be permitted to repeat the preceptorship next semester.

You were given a gift. The opportunity to do an unconventional preceptorship in a highly specialized area of interest to you. A unit offering both detox and in-patient rehab offers a wealth of experiences with patients in various physical, mental and emotional conditions, and could be used as a springboard for a job search in virtually any aspect of adult behavioral health, substance abuse, out patient clinics, inpatient med/surg, community health, case management, etc. I remember all too well the pressure to "cram" every possible learning experience into a limited number of clinical days, and can't begin to imagine how there could possibly have been absolutely nothing to do, especially since you have identified a number of performance concerns from your early days on the unit.

I suspect that your failure had little to do with small mistakes and everything to do with a lack of self responsibility, self direction, initiative, effort, etc.

Of course you can appeal. I doubt that will be successful. I highly suggest taking the time to do an honest appraisal of your performance and developing a serious plan for improvement should you be allowed to repeat this clinical experience. It might represent your best chance of persuading the program director that you can be trusted with another opportunity.

[TriciaJ, RN]

If you had absolutely NOTHING to do, then you weren't looking hard enough. You mean you weren't kept busy with tasks. But when you did have an actual task to perform, you seemed to have difficulty thinking through all the steps.

Why did your preceptor feel the need to remind you three times to get an apical pulse? Did you not acknowledge her the first two times? How on earth would you have managed a busy med-surg floor? I'm seeing a huge issue with self-direction and critical thinking. Critical thinking is not easy to teach someone; you have to be motivated enough to make the effort to learn it.

I, too, think you should apologize to the people on that unit for your attitude and lack of motivation. Then try to get your school to give you a second chance.

[Kabuto_]

These are some stupid mistakes. Especially the random insulin vial? Why didn't you tell the teacher it was lying there? Nervous?

[NurseStorm, BSN, RN]

If you only did "1 or 2 hours of actual work, if that. The rest was sitting around doing nothing or walking around aimlessly. And trust me, there was NOTHING to do." to me that is BY FAR your biggest mistake! There is ALWAYS something to do. ALWAYS. Talk to patients, read their charts, get their histories, research their diagnoses in depth. Make cue cards with the most relevant info of each diagnosis you encounter. Make a binder with notes/relevant info on diagnoses, meds, treatments, side effects etc. Offer to help others with their work. If nurses/staff are truly not busy at times, you could ask to hear some stories, learn from their experiences. Ask for their best advice for new nurses/common mistakes made by new nurses that you can work to avoid and educate yourself more on before graduating. Compile a journal of tips and things to avoid from their advice. Read relevant clinical information from books on the unit. Ask the nurse educator what types of extra courses or training do staff partake in that you could also look into. Ask the ward clerks if they need help with organizing charts. Do chart audits. I could literally go on for pages.

THERE IS NO EXCUSE TO WANDER AROUND AIMLESSLY FOR HOURS EVERYDAY!! I'm actually stunned that you did that and saw no problem with it and instead blamed the unit instead of your extreme lack of initiative and motivation. Think of HOW MUCH you could've learned if you used all those wasted hours doing the things I suggested above. I think your instructor would've been much more likely to let the other issues "slide" had you been a student with motivation and initiative to learn and grow, but since you weren't, she was concerned your growth wouldn't progress enough.

For example, after you made some of these mistakes you could've studied drug manuals and assessments in your wandering around time, and made up cue cards and highlighted actions needing to be taken before meds commonly given on the unit. You could've shown these to your preceptor to show you were working to expand your knowledge and grow your practice to become safe, competent and independent. So even though you didn't get the chance to give that med again, you could've shown her how you learned from it by doing this.. For the pulse oximeter, you could've researched best practice, policies, tips, things to avoid, things to be aware of etc, and wrote out something on that topic. (Nail polish can affect results, cold fingers can affect results, the bp cuff being inflated, etc etc)

It also sounds like your senior practicum was extremely short, a downfall to your school/program for sure. Not enough time to have the growth that my program had, where our final preceptorship was like about 8 weeks working full time on our preceptors schedule. Most of those (other than the insulin) were fairly minor things since you were under supervision and just starting, and had you a longer preceptorship hopefully things would've been improving. However, your lack of initiative and motivation was not a forgivable thing imo and the true reason you failed in my honest opinion.

If you are given another chance you need to COMPLETELY change your approach and outlook, and look at any extra time as a gift to learn more and more. DON'T BE LAZY AND WASTE TIME!! If you want me to write out even more things you can do I would be happy to. If you can change in this regard you could have a chance to become a successful nurse, if not.. you don't really deserve a second chance :/ I'm frankly baffled how you didn't realize to do these things on your own and that no one in your program ever emphasized never to be lazy and waste time like that? I'm not trying to be harsh/mean, just I'm honestly confused.

Again, in regards to your appeal, don't go in whining that you deserve a second chance and the unit was slow and stuff like that. Acknowledge you lacked initiative and present a plan of how you would make MUCH better use of time if given a second opportunity.

[Spurse32]

I know it was highly specialized and interesting, that's why I stayed. I actually volunteered myself for a lot of things. For instance, if a patient needed to be walked downstairs for an appointment, I volunteered. I volunteered to lead groups and that was one of things they said I was good at. The nurses were on their phones, chatting, watching youtube, etc. I'm not making this up, it was a slow unit and there wasn't things for me to do. And I didn't want to leave the nurses station always because if someone needed PRN or afternoon meds, I wanted to practice doing it.

It might sound crazy but if I had more things to do, like being on a med-surg or ER floor, I would have been WAY more focused and more energetic. When I get bored I tend to get uneasy and zone out. I love being busy and running around helping people, it's a challenge and keeps me engaged. That's my fault for not speaking up though and requesting a new site.

I always, always achknowledge people when they speak to me. I hate being ignored. I'm actually a very nice person. There is a chance though in the heat of the moment, I didn't, only because I was distracted and so new at doing the med process. But I honestly don't remember. There was no MAR in the pixus, we had write everything down before going to the med room.

I think if the insulin thing hadn't happened, I probably would have passed. It was bad, I know. And yes I was very nervous. The med room is the size of a bathroom and it was hectic with us trying to do discharges and pass meds. My nurse pulled the pts meds down and placed his bin of home meds next to the insulin, called me over, pulled out one bottle and a plastic pill counter thing and told me to count them. I never saw the insulin laying by itself. I only saw it next to all the meds. If I would have done that task from start to finish, that would HAVE never happened because the first thing I would have done is look at his MAR. But it did and if that patient went home and for some reason injected himself with insulin and got injured, I would be accountable and I understand that.

My clinical director somewhat empathized with me and said I can come back and finish in January and we would work together to find me a site that fits, I'm probably going to do that.

[Spurse32]

I wanted to respond to NurseStorm, I didn't see your post till after I responded again.

Yes you're right, I could have done all those things. I suppose my mindset was more of an application perspective and that I wanted to be near the nurses station, ready to give meds. I didn't walk around doing nothing for hours and I did talk to ALOT of people, including the patients. But thank you, I appreciate your thoughts. I should have been more creative in finding tasks to do. I even brought a NCLEX practice book but never got around to working on it. I just didn't want to seem like I was checked out.

[meanmaryjean, DNP, RN]

Since you are getting a (rare) second chance- you need to EXCEL. Your future depend on it.

[KRVRN, BSN, RN]

Well, you're an almost-new grad. You're inexperienced and have a lot to learn. This is expected, don't agonize over it. Do better next time

[Daisy_08, BSN, RN]

A slow unit should mean you are set up to do really well, so I don't understand what you are getting at. You should have ample time to research and get to help other staff with procedures.

I hesitate saying this, because I think the responsibility lies with you, but I never let students give narcotics on their own, or any meds until we are both comfortable. I do think that as a student you will make mistakes, when my students make mistakes I think it is a great opportunity for us both to learn, and in the long run it will benefit them (reduces anxiety about making mistakes, they now know what to do, and I can evaluate how they handle it). That being said your preceptor did not set out to fail you. I had an awful preceptor myself. She was AWFUL, but I did my best learned what she wanted (someone to do her work) and passed, and know I enjoy being a preceptor myself because I know what is like to have a preceptor who does not care.

I think your best bet is to repeat the course. You obviously wont get a job offer or any references from this last placement, nor does it seem you learned a lot. Get a placement in a different area, learn from but dont dwell on the past and try again.

[Spurse32]

I perform better with a steady work flow, with more things to do and more tasks to accomplish. I'm more engaged. But like I said, I could have been more creative in finding things to do. Still, I did whatever she asked me to do and more. I could have done research also. I'm not lazy, I'd rather be busy. When pts needed ppds, I asked if I could do them or practice drawing up the meds. There wasn't a whole lot of "procedures" going on. Patients were walking, talking, oriented. There was nothing in the evaluation about me not utilizing spare time or being lazy.

I don't think I can request a passing grade in good conscious because I didn't get what I needed to match the outcomes of this course. This is MY FAULT for not discussing this earlier with my clinical director. Could I have been more safe? Absolutely. And I think I would have if I was given the chance to work in a more traditional setting, with more opportunities to learn, fix and improve on my mistakes.

If anyone out there is a student nurse and is in a preceptorship that you don't think will offer you chances to learn and build toward your future, SPEAK UP. Learn from my mistakes. It never hurts to communicate with the powers that be.

[SHGR, MSN, RN, CNS]

If I could like NurseStorm's post a hundred times, I would. That is the attitude you should have approached this opportunity with from day one. If it was so slow, why did the incident with the insulin/busy with discharges and med passes happen? You probably could have prevented that if you had been helping your preceptor keep a steady work flow.

Reconciling a patient's meds without clearing the area of other meds first is a disaster waiting to happen. I hope you see the safety importance of staying engaged. Also, keep the attitude of not just your own learning (like pulling down the P&P manual in your downtime to review) but helping out on the unit. Do some extra physical assessments, engage patients in one to ones, talk with the case manager about what might be needed for someone's discharge, that kind of thing.

I precepted two BSN students for their final capstone clinicals in our outpatient clinic. The first one came the first day already having read- and with great questions about- prep material I had sent pertinent to our setting. Kept busy the whole time, always looking for new opportunities. The second disappeared a lot and just clearly was bored. Well, attitude is everything. Also, that was the last time a student was allowed in our setting.