Fellow nurses...does this make sense?

llg, PhD, RN · Feb 27, 2015

The student presumably knew (or should have known) that she was not supposed to do the skill without the permission and/or presence of the instructor -- and yet she did it anyway. She violated the rules and demonstrated that she cannot be trusted to practice within the school's safety guidelines. That violation of policy, trust, and safety is quite a serious offense and needs to be addressed firmly whether you agree with the policy or not. (She said she "did the foley," implying insertion.)

Trust is a critical component of nursing practice. If a nurse or student cannot be trusted, that's serious.

In this case, the instructor was not consulted at all ... did not know or "approve" the staff member supervising the student in this way, etc. To leave the instructor completely out of the loop was very wrong.

While the school may have poorly explained or over-stated the "under the instructor's license" issue ... there is an issue there. Instructors ARE held accountable for the behavior of their students by the clinical sites. If students are out of control and not following the established procedures, the school will be blamed by the hospital. And the instructor's abilities to control her students will be questioned if go off on their own and demonstrate poor judgment. It's not just the legal liability issue -- there are realities of "social accountability" that say that instructors do take some responsibility for what their students do.

canigraduate · Feb 27, 2015

Another point to consider is that permission to have clinical at a site is easily revoked. If there had been an adverse event due to the student's involvement without the instructor there, it could very well have escalated to the point where the school could lose their clinical privileges. This is another reason why clinical instructors hover over their students.

Whispera, MSN, RN · Feb 27, 2015

As an instructor of first year nursing students, I require students to do something with me the first time. Then if they do it right, the next time they can do it with their precepting nurse, if it's invasive. Before doing it with me the first time, also, they tell me exactly what they're going to do, how they'll do it, and all the rationales and other information they should know. They might have to demonstrate to me, as well. For instance, I have students show me they can draw up and inject injectables using saline and a styrofoam cup. It's a step by step process. Some never get to the point of doing it with their precepting nurse.

Being able to do things in lab, probably during another semester, means nothing. Their instructor might not have the same standards I have. They also might have forgotten everything they learned.

It concerns me that the student described by the OP LIED about doing a foley. This would be a more extreme violation of policy than inserting a foley, with a overseeing nurse present...

elkpark · Feb 27, 2015

Ultimately, it doesn't matter what the policy was at any school any of us attended; the issue is that that's the policy at this student's school, and the student violated the policy. When I've taught clinical, the school's policy was that students could not do any invasive procedures without me, the instructor being present. And I would be v. clear with the nursing staff about what the students were and weren't allowed to do and that they did not have anyone's permission to scoop up a student and help them do something invasive, regardless of how good a learning experience the individual nurse thought it might be, regardless of how much the student wanted to do it, regardless of anything.

Often these kinds of policies are not exclusive, or even original, to the school -- often it is the requirement of the hospital administration as a condition of taking students for clinical, but that doesn't "trickle down" to the individual floors and the nursing staff are not necessarily aware of that. But, as already noted, it's extremely easy for a school to lose a clinical facility for not following the guidelines and limits established by the facility and schools really do not want that to happen, as it is difficult to find enough appropriate clinical settings to begin with.

CT Pixie, BSN, RN · Feb 27, 2015

Like The Commuter, I've been in school twice in the last 5-6 years.

During my LPN clinicals we were NEVER allowed to do anything without our instructor present.

During my RN clinicals it depended on the instructor. If we were checked off for it in the skills lab we were able to do it with the instructor or with the floor RN IF the instructor was ok with not being there and only the RN was. I had the same instructor for 2 of my 4 nursing classes. I made sure to ask her what I could and could not do when I went to my out rotation to the ED. She had said she was fine with me doing anything I was checked off for (at that point I was checked off for everything you'd need to be checked off for) as long as the ED nurse was ok with it. She did mention that some of the ED nurses did not allow the students to do anything but observe while others went above and beyond finding things for the student to see/do/observe or assist with. I lucked out! My ED nurse was great. She had me pretty much doing everything I could do (other than IV pushes which were NOT allowed at all..ever even with the instructor present). I learned so much in that short 8 hours. I even stayed an extra few hours (the nurse was doing a 12hr shift) so that I could keep doing and seeing things. Best experience ever.

One of my other CI's would not let us do anything without her there. And even then, she was very reluctant to let us do anything above ADL, bathing etc.

blah_blah_blah · Feb 27, 2015

At my school, we were not allowed to perform any skills without the CI present. You could pass meds with the RN if you got permission first (some CI's didn't mind, others would absolutely not allow med passes without them present). I've never performed a skill without the CI and if I did I would have been punished. In a way I understand the school's reasoning, however if you're in your final semester until graduating and its a simple (non sterile) dressing change or something to that effect, I don't see the issue.

BuckyBadgerRN, ASN, RN · Feb 28, 2015

The following pertains to a student nurse who is a personal friend of mine. Said person was in clinical and got to follow a patient for the day. This patient was intubated and being moved to interventional radiology for a procedure. In IR the patient's assigned nurse asked the student if they would like to insert the foley catheter before the case. As the student nurse had checked off this skill in lab they figured it would be a great opportunity. In the end all the student nurse was able to do was setup the sterile field and the nurse inserted the foley for the sake of time. (we've all been there)
At the post-clinical meeting the student nurse said they got to do a foley. That's when things turned for the worse. It's my understanding that at this school of nursing the student is not allowed to do any nursing skills without the instructor present. Their justification is that the instructors license is in jeopardy if the student messes up. I can't find ANY literature to back that claim up. The Illinois nurse practice act, from my interpretation, reads like their is protection for nurses and instructors in the event a student messes up. Can anyone find something different?
It's my opinion that this school is not utilizing best practice in effort to enable their students to learn with the few opportunities they can get. What are they trying to say? 1.) That they don't trust their own lab instructors who check the students off on clinical skills? 2.) They don't trust the staff nurse who is overlooking the student?
The nursing school I went to promoted all hands on! If I was trained in the skill and had a RN with me then dig in! The opportunities for IVs, foleys, etc are few and far between. I say take them!
Anyways, I'm baffled by the school's punishment of this student. As a professional I'm embarrassed by the outright lies of the clinical instructor. The instructor went to the administration and said that the student verbatim said they INSERTED the foley even when questioned and told that they were not allowed.
I won't list what the punishment was for privacy of the student but the fact that the clinical instructor went to such great lengths to lie and write up a sworn statement boggles my mind. Are clinical instructors so eager to eat their young? Did the student do anything wrong? I'm thinking of telling them they are going to the wrong nursing school!

And boom. Right there is where you derailed for me. Up until this point my thought was "we're (and maybe you) aren't getting the complete story....

nurseprnRN, BSN, RN · Feb 28, 2015

At the post-clinical meeting the student nurse said they got to do a foley.

It concerns me that the student described by the OP LIED about doing a foley. This would be a more extreme violation of policy than inserting a foley, with a overseeing nurse present...

That's the big problem here. Like several of the above posters, I would be willing to bet that this is not the first time this student has skirted the rules and been a teeensy bit, ummm, er, unclear about what really happened. Students would probably be verrrrrry surprised to know how much instructors know what's going on with them when they think nobody's looking. Newsflash: There's almost always somebody looking who will tell the instructor the lowdown.

It's my understanding that at this school of nursing the student is not allowed to do any nursing skills without the instructor present. Their justification is that the instructors license is in jeopardy if the student messes up. I can't find ANY literature to back that claim up. The Illinois nurse practice act, from my interpretation, reads like their is protection for nurses and instructors in the event a student messes up. Can anyone find something different?

This is a common fallacy among even faculty who should know better, so I can't be 100% sympathetic to either side. Even though students have no licenses, they are adults and responsible for knowing what their scopes of practice are, and not exceeding them. In this case, the scope of practice is set forth by the school, likely in concert with the clinical placement agency. If the rule is, "No student will perform an invasive or sterile procedure without the presence of a SchoolName clinical instructor," then that is the student's scope. If the rule is, ".... without the presence of the instructor or designate (preceptor, staff RN...)" then the PACU nurse would have been OK to supervise the student in the absence of the instructor.

As a matter of fact, I wonder if the reason this happened

In the end all the student nurse was able to do was setup the sterile field and the nurse inserted the foley for the sake of time

was because the staffer observed the student not doing a safe job and took over. Said student may not have even realized this was the case; I've certainly seen that many times.

If the student screws up when the instructor isn't present it has nothing to do with the instructor's license. IF the instructor was present and allowed or coached the student to do something bad AND harm resulted, then she could have repercussions on her license, but that would be because she did something unsafe, i.e. (which means, "that is,"), she allowed a student to do something unsafe.

KelRN215, BSN, RN · Feb 28, 2015

OP's situation does not jive with what my experience has been (either as a nursing student or a staff nurse) but every school and every clinical placement is different. As I recall, I placed 1 Foley in nursing school. It was on a laboring woman and my clinical instructor was not present. I doubt she was even on the floor because our main placement in Maternity was on the post-partum floor and one person got to go to L&D every shift. I also don't think my clinical instructor was ever present for any straight cathing I did or NG tubes I dropped. It was always a staff nurse who came looking for an eager student. And it was never an issue. When I was a hospital nurse it was the same thing. The CI had 6-7 students on the floor, there wasn't always time to wait for when she was available when things needed to be done.

I can only recall 1 very unfortunate situation with a student... patient had a lumbar drain. I think student was taking vitals (which most schools would allow students to do alone) and somehow she got tied up or tripped over the patient's lumbar drain and ended up snapping it, necessitating an emergency procedure to replace the drain. We did not allow students to independently do anything with lumbar drains or EVDs, some of the time they didn't do anything with them even WITH their CIs because some of the CIs who took groups onto the floor weren't familiar with these drains themselves, so it's not like the student was doing something she wasn't supposed to be doing. Perhaps if the CI had been standing there she would have been able to call student's attention to the fact that she wasn't paying attention to the lumbar drain, I don't know. I actually think this student was so distraught after this that she dropped out of nursing school.

I can only recall a clinical instructor getting angry at a student for doing something without her (or in that case, the nurse assigned to the patient) once. It was our first semester of clinical. I think the nurse told the student that the MD had put in an order to remove the Foley so the student removed it. Clinical instructor was very mad. I don't think much came out of it.

trinitymaster · Feb 28, 2015

Related Horror Story:

Nurse at facility allows nursing student to place foley and the patient codes and dies.

I do not know all of the details, but this is what can happen. It might be just a coincidence or the catheter may have worked its way into the prostate and the balloon was inflated inside of the prostate (this does happen).

If I were the op's buddy's clinical instructor, then I would have reported the student and failed them for the clinical.

If you cannot follow the rules of clinical, then you likely will not follow the rules when you hit the floor and have much more freedom.

txnurse2014 · Feb 28, 2015

in my program the rules clearly state the instructor had to be present for invasive procedures.we had a student that went into a surgery setting and the doctor asked him to push some sedation meds and he was put in probation.

nurseprnRN, BSN, RN · Feb 28, 2015

in my program the rules clearly state the instructor had to be present for invasive procedures.we had a student that went into a surgery setting and the doctor asked him to push some sedation meds and he was put in probation.

Under these conditions-- a student is sent to OR to OBSERVE-- the staff nurses should have let everyone know that he was not a nurse and was not allowed to do anything but watch.

This is also a cautionary tale about physicians: They don't know spit about nursing education, and wouldn't know that a student was't able to administer a physician-prescribed medication.