Failing score on clinical evaluation (long story)

shibaowner, MSN, RN, NP · Oct 11, 2017

Unfortunately, not all clinical instructors are nice, nor are they always right. However, that is the real world. Personally, I would not expect a student to know everything in clinical. In addition, issues will come up in clinical that the lecture may not have covered yet.

Your goal is to pass. Talk to the clinical instructor and ask her how you can do better and pass. I would write everything down and document all. Make sure she tells you her expectations very clearly. You also need to explain the clinical is in conjunction with lecture, so there is material that has not yet been covered in lecture.

Also talk to your faculty advisor so she is aware of the situation and keep her apprised.

Get feedback from your clinical instructor after every clinical and document it. I have read horror stories of students who thought they were ok and got flunked at the end of the semester without warning.

Finally, what is your school's policy on clinical grades? For example, my school had a policy that after a serious clinical infraction, students gets a written warning. 3 warning and the students flunks the clinical.

How are you doing in the lecture portion of the class? If you are getting good grades there, then you know what is expected up to that point in time

Good luck

lilfayfay · Oct 11, 2017

Thank you so much! It's 2 clinical warnings until a failure and I have a B. Should I ask my faculty advisor if I can switch clinical instructors?

Ruby Vee, BSN · Oct 11, 2017

Hi guys! I'm on my 2nd year, 3rd semester of nursing school for the OB/Psych rotations. I got a failing score for my OB clinical grade yesterday and I'm very worried I'll fail clinicals. I feel like my clinical instructor is watching me like a hawk compared to my other classmates and since I'm not as outgoing as my other classmates I feel like she's targeting me that I'm not doing my job as a student nurse. I feel like she was not as understanding as my clinical instructor that I had during the first 2 weeks of this semester (she was supposedly to be our clinical instructor but had to focus on grading our theory/lecture grades since she's the only one this year teaching) and I feel like my new clinical instructor is purposely giving me nurses that aren't friendly or helpful towards students.
Anyways, here's my situation: I had a pregnancy induced hypertensive patient that was in labor and when the patient was able to deliver, my nurse asked if I wanted to give the meds to the baby. I asked if she wanted me to give the meds with her or my instructor and she said "Whatever you want, I'm kind of busy with charting." My nurse wasn't very helpful and only wanted me to do things if my instructor was with me. From the beginning, she wasn't willing to teach me what was going on with my patient. I told her that I'll get my instructor after I was finished assessing the mom's fundus and baby's vitals since I was supposed to assess the fundus q15 mins and baby's vitals q30 mins.
When I was done, I went to my instructor if she can give the baby's meds with me and she said that the nurse has to get the medications first. So I went back to tell my nurse if she got the medications out already and she said that they were sitting on the table. I went back out to get my Basic Needs packet to look up what each med was given for the baby but before I could do anything to look it up, my clinical instructor asked me if I was ready and I said let me look up the meds really quick to make sure I know what i'm giving. She said that I'm supposed to know all of my basic meds before coming to clinicals and that I should've looked them up earlier/before going to clinical.
I had another clinical instructor this semester that taught during the first 2 weeks of clinicals before my current clinical instructor took over and I remember her saying that "If you don't know a med. then that's where you look it up on your Basic Needs packet. I don't want you to give any meds w/o knowing what they're for."
When she quizzed me on each med I was able to list almost all what the purpose was for and route except for erythromycin. I told her that it was an antibiotic prophylaxis placed on the baby's eyes to prevent them from getting an STD. She marked me down because I didn't specifically say which STD-it was gonorrhea and chlamydia.
She also marked me down for not knowing what methergine was for. My patient had a complicated labor and wasn't progressing with the delivery because the baby was facing the wrong way so the Dr. had to come in and help reposition the baby. My instructor said to just observe how the doctor was helping the patient deliver the baby. I didn't give methergine but she asked me what's the purpose of it during post conference/lunch and why didn't the patient receive methergine-it's for the uterus to stop hemorrhaging/because the patient was hypertensive. She said, "don't you remember the doctor talking about it during the delivery?" I was only observing the delivery like she told me to-it was my first lady partsl delivery so it was interesting, and I don't remember the Dr. talking about methergine when I was there so I just took a wild guess and said because it might affect the fetus.
She also marked me down for not giving an accurate and cohesive report on my patient to her and my classmates during post conference-she just told me this time that she wants me to start from the beginning so I'm guessing I'll use SBAR next week when I'm at post conference but she only told me about this now; what about the previous 2 weeks that I had her?
So during the post conference when it was my turn to speak about my patient, I started with the main problems of my patient-how she was having severe SEs of diarrhea from the meds she was given (she was given hemabate + cytotec) and had 2nd degree lacerations. I said everything about my patient (i.e. what's her diagnosis, G/P/A/L, when she ruptured, what was her cervical dilation when I came in this morning and when did she receive an epidural, when did she start laboring and when she delivered the baby) except for why the patient came in the hospital.
I forgot because I was going to write it down on my careplans before leaving the hospital/didn't know she would grade me so harshly during post conference for that one problem-it was a very busy day, there was so much to assess and chart (I had a difficult patient-even my instructor agreed), and I'm still slow and trying to get used to charting on the computers so I guessed that she came in for labor when my instructor corrected me and said she came in to r/o labor. She marked me down for using wrong terminology, I said the patient came in for pre-eclampsia and she said it was hypertensive induced pregnancy but I asked her if they were similar since she gave me a sheet at the beginning on how to take care of mom's with preeclampsia/other hypertensive disorders of pregnancy.
Since my patient had hypertensive induced pregnancy, I had to do DTRs and clonus. She marked me down for not knowing how to do DTRs and clonus. I told her that I only remember being introduced to that for a brief moment during orientation but we didn't practice that during the skills lab in orientation (we only practiced the main things like: putting on tocomonitors and US on pregnant mom's tummys, reading strips, listening to FHTs, lung sounds, APGARs/Ballards, holding/changing baby, IVs, and foley/IV catheters).
I was practicing all of that during my free time in the skills lab and I told her that I'm doing my best and I'm usually the only one that frequents the skills lab. She also marked me down how I assessed for edema on my patient-she said I'm supposed to press down on the long bone for 5 secs but I squeezed both sides of the calves for a few secs. I told her couldn't you do either one and she said no.
Based on all of this, she gave me a 1/5 for preparation, 1/5 for medication, 0/5 for communication, 1/5 for assessments, and 2/5 for maternal-child care (b/c "I was unable to provide care processes w/o moderate supervision and prompting" and "unable to look beyond tasks at bigger picture for patient,"-idk what she means by that but all I know she was watching me the whole day.
I did struggle a little bit putting on the ID bands on baby and getting the baby's temperature once or twice on the first attempt but that's b/c it was just delivered or either crying and that was it; and that she had to orient me on what I should be assessing for my patient who had pregnancy induced hypertension.
She didn't give me time to read the sheet she gave me that morning-after she gave me the sheet, I went into the room to see if the nurses were giving report since it was 7 minutes within the start of clinicals but instead the anesthesiologist was giving the epidural to the patient w/ the help of the night nurse so I observed while waiting for the day nurse to come in to get report; after the epidural was given the day nurse walked in and I was helping both nurses fix the IV lines/epidural lines on the medication monitor since they were tangled up, when we finished my clinical instructor came in and I was still reading/taking in the information on the sheet she gave me-it was a lot of information + my nurse was cold/wasn't helpful/didn't orient me to the client either-I felt like I was alone this time.
For example, I asked my nurse if it was okay if I can chart the assessments for her since I know she's busy but she said "Idk, doing the assessments are my responsibility-I told her that I did some of the assessments and charted them for her with my instructor earlier and she said as long as you only do it with your instructor. This is my 5th week and this was the first time my nurse didn't want to do anything with me-all of my nurses I had previously this semester including the 2 other nurses before her that were strict wanted me to do assessments for them but they had to be there just in case the student was doing it right since we don't have licenses.
I just wanted to do something with that nurse that day since they're responsible for grading us and I even offered to do/chart VS for her but she said they're automatically recorded on the chart from the monitors by pressing "t" for time except for temperatures and respirations; Idk maybe the nurse thought I would slow her down since I'm a just student).
So what do you guys think? Shouldn't clinical instructors be understanding, encouraging, and create an environment conducive to learning for students? I feel like she's watching me carefully and grading me harshly. Should I tell the head of the nursing department about my concerns? I didn't harm the patient or baby and I maintained aseptic technique during the foley insertion/cleaned and changed the patient's chucks since she had constant diarrhea due to the SE of her medications (the hemabate and cytotec)/I emptied out her dirty linen and trash bags when full.
I did everything that I could-it's not like I sat in the nurses' station all day finishing up my care plans.. Any advice?

Forgive me, my specialty is ICU. But what in the world is a hypertensive induced pregnancy? Is that really a thing? Because it sounds to me as if the hypertension caused the pregnancy and we all know that's now how these things work.

Did you deserve a failing score? I wasn't there. But it seems to me that the instructor was very clear on why she failed you -- "1/5 for preparation, 1/5 for medication, 0/5 for communication, 1/5 for assessments, and 2/5 for maternal-child care (b/c "I was unable to provide care processes w/o moderate supervision and prompting" and "unable to look beyond tasks at bigger picture for patient."

First -- look up your medications before you go and get someone to give them with you. Your instructor and the nurse you were working with are both busy people, and you waste their time when you ask them for help when you aren't actually prepared to do the task you're asking for help with.

Second -- it doesn't sound to me (although as I said, I could be wrong as L & D isn't my specialty) as if the meds you were giving were unusual in the setting. So you should have looked them up and perhaps made drug cards on them BEFORE you came to clinical. Then it would have been a fairly simple matter to whip them out of your pocket and refresh your memory. And that would have demonstrated that you HAD done preparation before coming to clinical.

Third -- You do the assessment the way your instructor wants them done when you're with the instructor. No defensiveness or arguing. When you're with the staff nurse, you do them the way she wants them done. If either of the two corrects you, the correct response is to thank them for the feedback and then demonstrate doing it their way.

Fourth -- It sounds as if you're not seeing the forest for the trees . . . or you were unable to care for the mother and baby without prompting and supervision. And although you were focused on the tasks you needed to do, you weren't able to demonstrate that you understood why you were doing them.

Fifth -- that "0" in communication is a really, really big deal. And it sounds as if you deserved it. You are completely focused on how the nursing instructor and the staff nurse failed you, you were argumentative, you wasted their time and you couldn't answer basic questions about the care you were giving. That could have been either a knowledge deficit or a communication deficit, but when your response is defensive, argumentative or self-justifying that's a failure in basic communication in the clinical setting.

You're demonstrating a failure to look beyond your own nose or your own needs. That nurse didn't "think you would slow her down because you're just a student." She KNEW you would slow her down. It takes approximately four times as long to teach a student what you're doing and why as it takes to just go ahead and do it yourself. Four times. And that's a good student who is prepared, engaged, communicative and learns quickly. Teaching someone who isn't prepared, who is focused on something other than the patient or patients in front of her and whose communication skills are lacking takes much, much longer. Having a student chart vital signs doesn't "help" me, because I still have to look back through them. I'm responsible. Having a student chart assessments doesn't help me at all because I'm responsible for the assessment. I don't want a student charting something incorrectly, in the wrong place, charting an erroneous finding or failing to chart something significant. If they do, it's a lot of work to explain to them what they did wrong, why it was wrong, how to fix it and then make sure they did fix it and fixed it correctly. Much easier for me to chart my own assessment. A student who is resisting correction (as it sounds like you were) makes it ever so much MORE difficult.

Nursing instructors (and staff nurses who work with students) are SUPPOSED to watch you closely. It would be wonderful if every student had an encouraging instructor, one who created an environment conducive to learning. There aren't enough of those paragons to go around, and you'll have to make do with the instructor that you're given. It doesn't sound as if she did anything wrong. An "understanding" instructor may be detrimental to your learning. If everyone gives you a pass on poor performance, poor communication and lack of preparation -- which is what you seem to be looking for -- how will you learn? A good instructor holds you accountable. A good student holds herself accountable.

There's a lot of advice in this post -- I hope you'll read it, reflect upon it, internalize and heed it.

shibaowner, MSN, RN, NP · Oct 11, 2017

I think some folks are being too hard on this student. Did all of you know every single med needed BEFORE every single clinical? If so, then you have the power to see into the future. And none of you ever forgot anything? And did all of you know everything in, say, OB BEFORE the OB clinical? I seriously doubt it. I can only go on what the OP wrote. I think the OP is frustrated and coming here to vent. She sounds like a conscientious student overall.

1. I don't know how many Basic Meds are on this student's list. If it were just a few, then sure, they should know them. But not even practitioners have every single med memorized! That is why we have apps and cheat sheets. Even MDs double check med dosages and so forth sometimes. I assume that is why this student had a packet of this info - so she could look it up when necessary.

2. The OP wrote she did know all the meds except:

a) she said erythromycin was prophylactic for STD instead of specifically stating it was for gonorrhea. Technically, both the student and the instructor were incorrect. The purpose of putting erythromycin on a newborn's eyes is prophylaxis against "Ophthalmia neonatorum (ON), also known as neonatal conjunctivitis, [which] is an infection that causes inflammation of the conjunctiva during the first four weeks of life." The leading cause of ON is chlamydia, followed by gonorrhea. Personally, if I were the instructor, I would have prompted the student by asking, "Can you tell me which STD organisms you are protecting against?" At most, I would have deducted 1/2 point for this.

Evidence on Erythromycin Eye Ointment for Newborns

b) methergine - this is used to prevent and control postpartum hemorrhage. OK, so student didn't know this one.

3. OP was told her patient report was not accurate and cohesive. The instructor could have given better feedback to the OP, like: "Try using the SBAR format" "Next time, remember to include why the patient came to the hospital" The instructor admitted this was a very complicated patient, so it is understandable a student would not have given a "perfect" report.

4. Terminology. Both the OP and her instructor need improvement here. The term is "pregnancy-induced hypertension (PIH)" which is also known as pre-eclampsia. However, the preferred term is now gestational hypertension. At any rate, I see no reason to penalize a student for using the term pre-eclampsia unless there is something I am missing here.

5. Not knowing how to do DTRs and clonus. If the skills lab didn't teach these, then the OP has a point. This instructor is also creating an atmosphere of fear in which students fear admitting they don't know how to do something. For goodness' sake, this is one clinical day. I would have told the student to watch some youtube videos and be prepared to do these next time. If it turns out all the other students knew how to do DTRs and clonus, then ok, deduct a point.

6. I believe the OP was to assess pitting edema. This is from one of my favorite resources, American Family Physician: "The physician should describe the location, timing, and extent of the pitting to determine treatment response. Lower extremity examination should focus on the medial malleolus, the bony portion of the tibia, and the dorsum of the foot." Both the instructor and OP need improvement here.

Edema: Diagnosis and Management - American Family Physician

Based on what I read, I believe scores of "1/5 for preparation, 1/5 for medication, 0/5 for communication, 1/5 for assessments, and 2/5 for maternal-child care (b/c "I was unable to provide care processes w/o moderate supervision and prompting" and "unable to look beyond tasks at bigger picture for patient" are unduly harsh.

Rereading the OP's post, I sense there may be something else going on here. The OP seems frustrated and made a comment that "I didn't sit at the station working on my care plan all day."

Now, for the OP, I do have some constructive criticism for you.

1) I don't know your school's policy for clinicals. However, I had to be at clinical one half hour to one hour before clinical started, so I had time to read each patient's chart, review orders, look up stuff, and so forth. Or we were expected to go to the hospital the night before to do the same, if the patient assignments had been posted for us.

2) Communication - as the OP stated, try using SBAR next time. Also, have you received negative feedback for your patient report previously? If so, what are areas you need to improve on? Work on those.

3) Please talk to your academic advisor ASAP about this. She can give you the best advice. As far as changing clinical instructors, that is generally not done. Part of being an RN is dealing with difficult people.

4) Is there something else going on here? Have you had other issues with this instructor or with other students? Did you have other bad clinical days on this rotation? If this is just one bad day, learn your lessons and move on. If this keeps happening, then you need to do some soul-searching and figure out how to address problem areas.

5) Suck up to the clinical instructor! Be humble and sincere, publicly praise her and so forth. Suggest remediation activities when she criticizes, like "next time can I demonstrate this skill for you, talk to the group about condition x, medication x" etc. You just need to pass.

In conclusion, most of us have had at least one bad or mean clinical instructor. And not all RNs are nice, either. Sometimes they are just stressed out from being busy, but some are just plain mean and not even very good nurses, as I know from being a patient. And not all RNs are great at dealing with students. And clinical instructors make mistakes, too.

lilfayfay · Oct 12, 2017

These were her previous negative feedback but they weren't as harsh as this week's. Nothing that was below a 3 to catch my attention.

"Lacked basic needs for PPROM patient, struggled with appropriate terminology." It was during post conference that I got confused between PROM and PPROM so she erased the 5/5 my nurse I had that day with a 3/5. I don't know what she meant for basic needs for PPROM cause I looked through my 40 page packet under L&D and it's not even mentioned on there.

"Lacked appropriate terminology, lacked ability to communicate assessment findings without moderate prompting." I don't know what she meant by this my nurse was okay with me that day, I should've asked her what she meant by that. 3/5

"Do not leave any grades blank unless in NICU with a non-normal newborn." 0/5 -> 3/5

"Continues to struggle with terminology and concepts, however she is improving every week." 5/5 -> 4/5

"Struggled with foley placement in OR." This was my first time inserting foley catheters in a live patient. During my Med Surg rotation, we didn't have that much opportunities to insert foley catheters. I only took one out and it was from a male patient. 4/5 -> 3/5 (even though the nurse that was with me that whole time wrote a 4/5, my instructor wasn't even in the OR with me).

"Needs to work on confidence in communication" I charted physical assessments, manual vitals like oral temp and respirations, and documented them for my nurse. 4.5/5 -> 3.5/5

I did have a problem with a previous clinical instructor but that was because I wasn't practicing my skills in the skills lab like the IV meds when we first learned how to work the pumps and give IVPs through the line. Now it's something completely different-it's the DTRs and clonus that we never practiced during skills lab for orientation. They only talked about that topic and showed the class about it briefly. I'm actually doing work, it's not like I'm slacking. Maybe there's a miscommunication on both my part and my clinical instructor's part. Maybe I do need to review the medications on my packet every night before clinicals if that's what I have to do but there's too much medications on there. Like this week I was in L&D but she marked me down on the erythrocyte med that was listed under NICU and the methergine med that I didn't even give-it was what the Dr. was probably talking about briefly during the delivery but I don't even remember b/c I was watching the delivery since it was my first time seeing a lady partsl delivery.

Yes, this was my first bad day on my clinical rotation.

And thank you so much for understanding my situation. You are the true embodiment of what a nurse should be!

Orion81RN · Oct 12, 2017

HO-LY CRAP. I'm going to disagree with many others here and say oh hellll no. It absolutely sounds to me like she is extra harsh....and I had some pretty harsh instructors, and I sucked it up. No advice for you, just a sympathetic ear and fingers crossed for you.

Here.I.Stand, BSN, RN · Oct 12, 2017

You are the true embodiment of what a nurse should be![/Quote]
RubyVee is too... just saying.

lilfayfay · Oct 12, 2017

Thank you everyone for your feedback. I am reading both sides and am keeping an open mind.

DesertRosee · Oct 13, 2017

Yeah girl you just have a tough instructor. It's hard to really judge because everyone's clinicals are different and our expectations maybe different. The only thing I would have done differently is look up the medications prior to getting my intstructor, but other than that I don't really see any glaring issues.

Secondly, this isn't your fault but having the staff nurse grade you seems very unnecessary and like it's just more paper work for them to fill out. Your instructor is supposed to be the one with you and teaching you not the staff nurse. This may be why you perceived the staff nurse to have been distant.

For documentation we absolutely cannot document on the computer without our instructor first verifying and confirming the information. Literally our instructor said if anyone of you save the information before I see it I will fail you on the spot. This is legal documentation and if I was the staff nurse I wouldn't want a student documenting without their instructor, and I would always do my own assessment and document. After all it is their patient ultimately.

Keep your head up girl and try to make the most out of a crappy situation.

kp2016 · Oct 13, 2017

Thank you so much! It's 2 clinical warnings until a failure and I have a B. Should I ask my faculty advisor if I can switch clinical instructors?

I think you need to focus on the bigger picture. I have read your post through a few times and what really stands out is that you accept no responsibility for your poor grade and have no plan to improve. Your entire post is about blaming others.

You have listed what amounts to several typed pages of small issues. I actually agree with you that all of them are small but when you put them all together it gives a poor overall picture. It is also worth keeping in mind that your instructor likely also has detailed notes to back up the grades she gave you and i'm going to guess she may well have other points you have over looked or the same ones that sound significantly worse in her account. Asking for a new instructor may do you more harm than good as it won't change your current grade or the fact that your instructor will be watching you even more closely if your school declines your request and notifies her of it.

The reality of nursing school and being a New Grad or even an experienced nurse on a new unit is that you will be judged on your performance and sometimes this will be by nurses who don't seem to like you or who seem to be judging you more harshly than they appear to be judging other nurses. I would advise you to be more aware of the feed back you are getting before it gets to the point of a failing grade. The initial 3/5 was an early warning to improve not an acceptable passing grade. Try and make time to prepare before each clinical day, review your basic needs packets and try and learn the main drugs and assessments, also pay attention to how your classmates are giving their reports in the post conference and try and follow the pattern used be the students who are getting great feedback. SBAR is designed as a reporting tool to notify of a new/ emergent pt condition its not really an appropriate format for a handover or pt summary.

Good luck.

lilfayfay · Oct 13, 2017

So instead of using SBAR, use SOAPIE?

Failing score on clinical evaluation (long story)

Do I deserve the failing score she gave me that day?