How do I respond to a bad Clinical Review?

[ZBianca]

Hi everyone. This is my first post on any nursing forum ever and its not a happy one. I'm a first year nursing student and last week I completed my first week of clinical placement in a Rehabilitation Unit. The patients on the ward I was on are severely brain damaged and have multiple issues, including feeding, ambulation and personal hygiene as you might imagine. On orientation were assigned an AIN or an Assistant in Nursing whom was supposed to coach us over the week. I felt confident and looked forward to the experience, but I soon felt pressured to perform at a level well above my comfort zone. I am a mature age student, over 50, and all of this was new to me. I needed time to understand how to transfer patients from bed to chair using belts, trolleys and hoists, understand the idiosyncrasies and needs of each patient and to act in manner that ensured safety to all. To be honest, as this was my first ever clinical placement, I didn't feel comfortable showering those patients on the first day, but I was learning and gaining experience. Nevertheless, my facilitator walked in on us on the first day, that is the AIN and myself and asked how I was doing, to which the AIN replied "lacks confidence", which I considered unfair. At that point I was less than 2 hours into my placement and I was branded for life. The label stuck. Even though I subsequently performed my duties within my scope and abilities, it was never quite enough. As it turned out though, I was happy with my experience and enjoyed my time there having learnt many new skills. In fact, I even bought the nursing staff a departing gift and thanked them for their assistance and direction. However, on the morning of my second week, whilst on another ward, I was approached by my facilitator whom said that I had received a bad review from the ward nurse for my first week. I was shattered, to say the least. My impression was that I was doing fine, to the point that I was considering applying there for a job in my graduate year. During the week, no one complained about my performance, no one took me aside and lectured me about having messed up. Yet, here I was standing in front of my facilitator being told that I didn't attend to my duties and that I went missing from the ward for 2 hours on one occasion without explanation. The truth is that the duty that I supposedly didn't perform was refused by the patient (whom was well within his rights to do so). Also, we were always told by our college that on the wards we were there to learn, not replace staff, so when the patient refused to shower and the AIN (temporary staff, not my original AIN) suggested he be sponged, another student walked into the room and began assisting her I volunteered to make the bed instead and I wrote this up in the patient's notes. As for being away from the ward without leave, that would be very difficult if you consider that I took a patient to orthoptics, incidentally on the same ward, stayed with him until the consultation was over, bought him back to his room and then attended the weekly case management meeting, which included the medical personnel, all of allied health, some nursing staff, my student colleague and the director of nursing for that ward. So, how that is meant to be an unjustified absence is beyond me, nevertheless the following Monday morning I was reported to my facilitator as being absent (even though I sat next to and spoke to the director of nursing). In fact, on my last day of my first week when I asked permission to briefly leave the ward (to purchase the nursing staff that gift I mentioned) the duty nurse simply answered "yeah, whatever", seemingly unconcerned about my actions. In any case, due to the early morning routine, the afternoons were fairly quiet and I found most of the nursing staff either chatting or playing computer games at there station. On the other hand, I used the down time to follow patients to their consultations and even attended a ward round with the physicians, activities encouraged by my university.

I feel that I have lost face with my facilitator, whom says that she believes me although I still sense some doubt, despite the fact that I can establish my whereabouts at all times. I feel totally ashamed of my review even though I know I did nothing wrong and at my advanced age I started questioning why I wanted to put myself through all of this.

What should I do. Any advice would be welcomed.

[DisneyNurseGal, BSN, RN]

I am sorry this is happening to you. In my experience, you can not change people's perception of you from events that have happened in the past. Next clinical, you might have to work twice as hard to overcome this perception. I would sit down with your facilitator (whether it is the same one or a new one) and say this is what happened last time, I want to change this idea of me, what can I do differently this time.

Also, in nursing, we are constantly criticized or critiqued, so you need to let this roll off your back and start looking forward. I too was a non-traditional student in Nursing School, and that can work to our advantage with perceptions of experience and wisdom. Build on your strengths, open communication and be gracious and accept criticism.

Good luck to you

[AOx1]

Hmm, from what little I can see from your post, you might benefit from better communication with your facilitator. In nursing, there are some things you "fake until you make it," including confidence in working with patients. I say this with caution, as this is not appropriate in all areas. Think about being the patient. Research everything you are doing, and use every opportunity as an opportunity for education. For example, let's return to your transfer example. Let's say you are about to transfer Mrs. Smith using a gait belt. You have been trained in how to use the gait belt, and feel safe in your ability to do so, but you are still nervous about interacting with the patient, who is unfamiliar to you. This confidence is OK to fake. For example, you might say "Mrs. Smith, I am Jane, your nursing student for the day. I am here to help you move safely from place x to place y. I'm going to be using this gait belt to help you move more safely. When I help move you, tell me if you feel unsteady. We can go as slowly as you need." You might also caution her not to grab your neck (patients sometimes do this if they feel frightened). Just think out loud. For example, if you are checking her for non-slip footwear or the floor for stray items, you can say so. This gives the patient confidence in you, and gives you something to talk about. You could also talk about why you are doing what you are doing. Ex- if you are ambulating a patient with a gait belt after surgery, why is ambulating important? What is the function of the gait belt? You can tell your patient this.

So now let's look at a different example where it is not ok to fake. Let's say you are getting ready to use a new lift that you have never seen before. Just as you did, you would first look for assistance to make sure you can safely operate it, to make sure you are well trained. Some things in nursing allow for faking confidence (ex- acting calm in your first code, even when you'd rather run away; speaking to a patient the first time) until you develop skill. For these things, the patient wants to know that you are competent and confident. It helps them feel that they are in good hands. For other things (patient safety, new skills), always gain confidence through practice and asking questions.

I say all this to convey that I think perhaps you need to demonstrate to your facilitator that you can be confident, but that you know your limits.

One other area for potential improvement might be communicating with your facilitator about opportunities off the unit. Although seeking these opportunities is encouraged, I would first check with the facilitator before ever leaving the unit. Use it as a chance to practice report in a small scale. For example, you might first check with the assigned nurse (and then your facilitator) and say: "I've just checked on Patient Jones. His vitals were (list vitals)and his last blood sugar was y, he denies pain, is AAO, and he is resting comfortably. His wife is in the room. I've assessed for any side effects from his am meds and found none. I provided education on topic y. I've charted all interventions and responses, and provided his am care. I have the opportunity to attend event z on the third floor, which is scheduled for an hour. Is there anything else I can help you with, or do you mind if I attend?"

If you are given permission to attend, you could then report back to the facilitator: "Thanks for the opportunity to attend event z. I learned a lot about ________. Is there anything you would like me to do before I report back to my patient assignment?"

You may have already done this, but your post doesn't mention it.

I would just use this as an opportunity to communicate more thoroughly, and display confidence as you are able. The only way you build confidence is to do something and keep practicing. You will receive a lot of feedback as a student. I would sit down with my facilitator, note that you've reflected on the feedback, and offer some possible solutions to better demonstrate confidence and communication. Check to see if those solutions are acceptable. If not, ask what would be. Be very proactive. As an older student, you have much life experience to draw on, and this can be a real asset. Try not to see all feedback as a precursor to failure. You can make it a precursor to success.

[ZBianca]

Thank you both for the encouragement. I will be the first to admit that I wanted to start slowly, but that wasn't from a lack of confidence, it was more a case of being over cautious. On my first day I was presented with patients with such severe post acute disabilities due to trauma that many will never fully recover. I didn't want to drop anyone, I had never seen some of the equipment they use on the ward and I had no idea how to use their hoist. For example, no one explained which positions to use for the harness and by the time I asked the OT the nurses had already formed their opinion. As far as my facilitator is concerned, she passed me and was good that way, but her comments in my logbook only reflect what the nurses on my first ward said about me. We would only see her fleetingly during the day, she would come in during the day to see how we were going then we would meet for an afternoon debriefing. If my performance was so poor during the day or week, I would have expected that the issue be bought up and addressed. It wasn't. No one said anything until the following Monday morning, when I was already another ward. Also, my facilitator based her logbook review of me on my first week's performance rather than the full two weeks, which I think is completely unfair because two nurses, whom I have never met before in my life, complemented me on my nursing abilities and high level of confidence. Wow, funny thing is I didn't change a thing and you might conclude that after a week my confidence levels were higher and I would agree, but I don't think that was the case. It was more a branding. The nurses on the second ward were simply seeing me do my job without a predetermined filter. Unfortunately, the damage was done. My logbook, at the hand of my facilitator, now states that I can't accept criticism. My issue is that I was accused of not being on the ward for 2 hours without leave and not performing my duties. That is not a criticism. A criticism is stating to someone that they have made an error and should correct it, an accusation is telling someone that they have done something that they should not have done. I defended myself of the accusation by explaining my position to my facilitator in a clear but non argumentative manner. I was really really surprised at the accusations made against me as I had no idea what the nurses thought of me, even when they accepted my parting gift with a smile!!!! I was literally blown away. If that is not being able to accept criticism, then so be it, I can't accept criticism. Now its official. Anyway, next week I'm in a new hospital and a new ward. I'll take your advise and keep you posted. Thanks!

[AOx1]

Remember, though, that there will always be people who unfairly criticize. As a nurse educator, I have seen student evaluations that would indicate that I am evil incarnate, and those that would indicate that I am the best instructor in the known universe. Neither is true. The truth is that I excel at many things, have many things at which I need to improve, and some of what I do is average. Students can't see the whole totality of what I do anymore than an instructor can see the entirety of what ten students do in a typical shift. Make what you are good at more visible.

All we can go on is what we see for ourselves and what we are told. Look for patterns in feedback, both negative and positive. That is where truth and useful feedback can usually be found, not in the outliers, but in the patterns.

Right now, I can sense your frustration, but try really hard not to feel or act defeated. There are a minority of nurses who like to prey on new students, but most want to help. The reality is that most people are not comfortable giving negative feedback directly to others, and will take the easy way out by reporting it to the instructor.

You can't control what others say about you, all you can control is your response to it. I spent many years struggling on this board because people often demean nurse educators. "Those who can't do, teach, etc" until I finally realized that I don't care. I earned my doctorate as a full-time student, full-time educator, and still worked 14-hour shifts at the hospital each weekend, yet I was told over and over that educators are worthless, not real nurses, only there because they can't succeed in practice. Guess what? I finally realized that I don't care. I am a great nurse. Most of my students think I'm a great educator. I can't make those people who think educators are idiots change, and I no longer want to. I just want to focus on improving myself daily. Let them say what they will. Know youself well enough to know when feedback has truth, and blow off the rest.