Failing score on clinical evaluation (long story)

[lilfayfay]

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?

[Ruby Vee, BSN]

So instead of using SBAR, use SOAPIE?

Which format does your school prefer? Which format does the clinical site prefer? Use the format preferred in the setting, which may mean giving report in SBAR format and in post conference use SOAPIE.

[lilfayfay]

Okay thanks!

[lilfayfay]

Here's my SBART format:

S-S.Z. is a 21 year old female who has gestational hypertension. She is full code

B-She came in with a high BP 140/91 and was feeling mild regular contractions. Her dilation was 3.5, effacement: 50, and station: 0. FHT 125 and UC 3, 50, and mild. Her doctor is Dr. H. She came in to r/o labor. She is 40 weeks pregnant. She had a cholecystectomy 2011. She is G:1 P:0. Her MPV lab was high-11.7 with a low platelet count of 25.1. Albumin and A/G labs were low. They were 2.8 and 0.8. Her Alkphos was high, 208. She has ketones, protein, leukocytes, and squamous epithelial cells present in her urine. They were 2+ for ketones, 1+ for protein, trace for leukocytes, and 1+ for epithelials. She's on LR 125 mL/hr and oxytocin 2munit/min. She has a R ante cubital saline lock. She's on continuous FHTs/UC, BP, HR monitoring and pulse oximetry. Her daily meds are acetaminophen hydrocodone Norco 5/325 for pain, Docusate sodium for constipation, and ferrous sulfate for iron deficiency.

A-Her pain is 0/10. Patient received an epidural, she can move her legs but cannot feel them. She's on bedrest, fall risk precautions, and on a clear liquid diet. Teaching needs are breastfeeding and newborn care. She is a.o. x4, PERLLA, her lung sounds were clear to all lobes bilaterally, heart sounds S1 and S2 present, cap refills were

R-continually assess and massage fundus and note rubra every 15 minutes, check baby's vital signs/heart sounds/respirations every 30 minutes. Assess for diarrhea, clean and change patient. Hold docusate due to diarrhea. Assess for any pain, nausea, and vomiting. Give meds for nausea and pain. Assess if patient still feels numb in legs due to epidural. Assess characteristics and record amount of vomit.

I texted this to my teacher and she said to change it to either PP or Labor b/c I had a mix of both.

[xoemmylouox, ASN, RN]

I will say there are great instructors, mediocre instructors, and then the very few - really crappy ones. Often the ones that seem the toughest are doing their best to make you the best and strongest student/future nurse possible. Often they are tough because they want to set the bar high and make you rise to the occasion. Very few are truly "bad". I can't really comment on yours because I do not know them and I wasn't there for your clinical assignment. I will say that you know what the expectations are - so rise above. You will encounter PLENTY of difficult nurses/leadership once you are done with school so learning how to interact with them now, will only serve you later.

Best of luck.

[babychickens]

Having just completed OB clinicals this is so fresh in my mind. I notice you ended your post by saying you had completed tasks like emptying the trash, etc. It seems to me that your instructor is a stickler for critical thinking. Anybody in the hospital can empty a trash can. It takes no studying or prep time to notice it and do it. I had a day last semester when I showed up for clinicals not as well prepared as I should have been. I vowed ever after to be better. Now, especially if its a new area, OB, NICU, L&D, etc., I either wake up early (or stay up late the night before) and review assessment criterion, common meds, and what the schedule should be like for the day. It seems to me you're in a very reactive mode as you go through nursing school and it's time for you to become PROactive.

[lilfayfay]

Do you know the schedule of what a typical PP day will be like? This will be my first time in PP

[lilfayfay]

Update: So she said I passed but my overall grade in clinicals went from a passing grade to a failing grade during this Thanksgiving weekend. It went from a 75%, to a 73.12%, and now it's a 71.93% which isn't passing. The minimal grade I need to get is a 73%! I feel like all of my hard word and efforts were all in vain.. I don't understand, last week she said that I passed, maybe I got a failing score for my last assignment that was worth 5% of my grade? It was an easy assignment, it was to write about one ethical dilemma that you experienced in clinicals, worth 40 points and I calculated my grade and it looks like she must've given me a 2/40 which is a 7%. If I did that bad on the assignment, she might as well have given me a 0% unless it was a typo? There was no other assignments left for my grade to drop that drastically.

[Ruby Vee, BSN]

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.

I realize that this is an older post, but I think you're not being hard enough on this student. Hopefully, the student has heeded some of the better advice she has been given and improved her clinical performance.

First, the student knew what meds she was going to have to give the patient before she asked either her instructor or the nurse to help her with the task. The time to have looked up the meds -- if she hadn't already made drug cards on them at home because she had researched the patient the evening before or had made drug cards on more common medications -- was BEFORE she asked for help with the task.

Second, the original poster sounds like a student with poor communication skills, a bad attitude (defensive and argumentative) and inadequate preparation for the task with which she was asking for help. If that is the case, then the grade was probably accurate, even if the OP was disappointed or upset about it.

Students may not like the manner in which feedback is delivered -- and not everyone is good at giving feedback. But it is up to the student to extract the nuggets from the interaction and use them to improve her practice. It's up to the student to LEARN, not really up to the bedside nurse to TEACH. If the preceptor or bedside nurse is trying to teach, that's half of the interaction. The student doing their best to learn from the person they're assigned with is the other half of the interaction.

[Ruby Vee, BSN]

Update: So she said I passed but my overall grade in clinicals went from a passing grade to a failing grade during this Thanksgiving weekend. It went from a 75%, to a 73.12%, and now it's a 71.93% which isn't passing. The minimal grade I need to get is a 73%! I feel like all of my hard word and efforts were all in vain.. I don't understand, last week she said that I passed, maybe I got a failing score for my last assignment that was worth 5% of my grade? It was an easy assignment, it was to write about one ethical dilemma that you experienced in clinicals, worth 40 points and I calculated my grade and it looks like she must've given me a 2/40 which is a 7%. If I did that bad on the assignment, she might as well have given me a 0% unless it was a typo? There was no other assignments left for my grade to drop that drastically.

It sounds as if you were pretty close to the pass/fail line and any little thing may have tipped you over. Perhaps there was additional feedback from the nurses at your clinical site that she wasn't aware of when she talked to you. Perhaps the ethical dilemma that you discussed wasn't really a dilemma (because there was a policy already addressing it or some other reason) or your interpretation was flawed. Perhaps she took off points for spelling, punctuation and grammar. I don't know the specifics, of course. I'm just trying to help you think through why your grade may have dropped 4.07 points.

If you did fail, your hard work wasn't all in vain. You've learned from the experience, and when you repeat the class that will stand you in good stead.

My best advice to you is to seek feedback from your instructor, the nurses you worked with and even some of your cohort, if you feel comfortable discussing it with them. Don't go in with a defensive attitude -- go in humbly, with the attitude of seeking help in your learning process. At least some of the advice and feedback you get will be good, helpful information if you accept it in the spirit of learning. Some of it will probably be difficult to hear. This is where your attitude and communication skills will either help you or hurt you.

I had an extremely rough start to nursing, and my communication skills were inadequate at best. I've learned over the years that it isn't so much what you say as how you say it. You may benefit from reading some good books on communication, dealing with difficult people (you may recognize yourself as one of the "difficult people" as I did), workplace relationships (even though you're still a student, the principles will still apply).

Failing a class isn't the end of the world, and not even the end of your nursing aspirations. It just means you've got a head start on the rest of the class when you repeat it. I hope that you pass the next time around, and that you pass with flying colors.

[windsurfer8, BSN, RN]

Are you going to ask the hospital to give you a different doctor to work for? Figure out how to successfully navigate the situation. Are you going to be asking for a change of doctors, RNs and patients every day? You assess and figure out what to do. Ask the ones who are passing for advice. Study harder. Push THROUGH and succeed. Your post has a lot of "she said" "she did" etc etc etc. Get your assignment and complete the task at hand. Move onto the next.

[caliotter3]

Are you going to ask the hospital to give you a different doctor to work for? Figure out how to successfully navigate the situation. Are you going to be asking for a change of doctors, RNs and patients every day? You assess and figure out what to do. Ask the ones who are passing for advice. Study harder. Push THROUGH and succeed. Your post has a lot of "she said" "she did" etc etc etc. Get your assignment and complete the task at hand. Move onto the next.

All a form of "growing up" and taking responsibility for oneself.

[lilfayfay]

Update: Hello X, I would like to meet with you after pharmacology tomorrow.

Thank you.

Respectfully, Professor X