Reaching a dedicated, intelligent nursing student who has trouble with clinicals

Tait, MSN, RN · Apr 1, 2013

"Dumped on the floor without a road map" this rings so true to me. Even as a seasoned nurse now, I clearly remember those days from school and my first year or two.

In school I was someone who had to have multiple highlighters, draw pictures of concepts, and see patient conditions in action in the hospital setting to understand them.

When I started nursing I was determined to create a tasking system. Something I carried in my mind was "this patient is a person" so my first task was to make them feel like that. I quickly found that you need to set up a rapport, within five minutes or so, with your patients. I would come in, ask how they were, tell them I was a student and I would be taking care of them all day and if they needed anything to call me and I would get it taken care of. During this time I was assessing. Color, breathing, touch the feet for pulses, look over the room for proximity of items, O2 tubing, IV lines etc. This portion gets more and more natural as you go on in your career.

The point here is combining tasks. Chat and assess. Ask about pain and immediate needs. Then let them know you have a few others to see and will be back shortly with the next task (meds, bath, etc). Think about it as a waitress. You stop by, ask the table how they are, assess drinks and needs, address quick questions about the menu, and then let them know you will be back in a few minutes.

Do this with all of your patients, spending 5-10 minutes per room and you have a rapport, a commitment, and a handful of early information.

Now look at what is next. Do you need to get drinks (medications) or is there 30 minutes to do your assessments? Let's say one patient needs meds before 8 and it is 7:55, then rest have 9 am meds. Grab your stethoscope and the early med and head in. Do your head to toe assessment, reassess needs (how is your meal), and then head to the med room for the next priority patient. If someone calls out in the middle for pain meds, finish your assessment, then go deal with the pain med. Stop into the room of the patient with pain and let them know you are going to get their meds, while assessing their pain level so you know what to bring in.

My jist here is nursing/clinicals is about combining steps. Just like when you do a dressing change you don't want to run out of the room for each supply individually. You assess the wound, look at what supplies were used before, then let your patient know you are going to gather your stuff (get the salad, appetizer).

Also creating a one page sheet where you can track the more tasky aspects, med times, glucose checks, is very helpful. Have all your patients on one page so you can quickly see where you need to move to next. Look at what the nurses on your unit use for this "brain sheet" and then create one entirely your own. Make sure it works for you. I used to have a grid for each patient with times and then I would highlight times when meds were due. That was a small part of it, but for me it gave me a fast visual cue as to where I needed to be next.

As far as your instructor, don't take his/her issues personally. Instructors are overwhelmed with students who are entering a demanding field with little experience and confidence. I had an instructor that failed a student because she broke down at the bedside of a patient with stress. This gal is a nurse now and all is well. I learned that day that I had to just move on and show I could handle. Prior to this I had been flunked by a clinical instructor for not being focused enough. It held me back an entire semester, however I went on to mentor the next class and do much better, learning more, because I had created a better environment in my life to support being able to focus on school (working during school and dealing with kicking a roommate out is taxing).

If your instructors aren't giving you good feedback, look to other students. Who in your class appears to be moving smoothly through clinicals Ask them what their system is. Ask to see their organizational style. Perhaps in the end you will find, like me, they did better in clinical than they did in class, and there can be some kind of educational swap. Your brain sheet for my ability to take the tests/learn the info.

Hopefully this makes sense. I was a waitress all through school and felt it taught me how to manage clinicals the same way.

Best of luck,

Tait

onewill · Apr 1, 2013

Wow, that is great feedback! The most reassuring thing you shared with me is the experiences of "near" failures that ultimately turned into successful nursing careers like yours and your classmate. I have just withdrawn from my third semester not because I am not "smart" enough but because my confidence was shot and by the end, I was beginning to make silly mistakes which compounded the criticism from my instructor who already had me in the cross hairs. Again, a mental focus issue. So like you, I am now set back a semester but am trying not to lose hope and to believe that just because I have hit this wall, I can still go on and be a good nurse. I know I'm salvageable !

I welcome any other feedback and additional suggestions from others who have walked the path or from other clinical instructors. Thank you !

daisy78 · Apr 1, 2013

I am a clinical instructor. Where are you struggling specifically? What are you not getting done? How many patients do you have?

Very basic, but our flow tends to be:

-Report (you should be getting an idea from the RN about what the patient's needs are and plans for the day)

-Introduce yourself to patient and explain your role

-Assessment and vitals

-Helping patients with breakfast if needed

-Bathing/Hygiene

-Medications (bathing and medications are often switched with one another depending on the flow of the day)

-After medications we can focus on other tasks that may need to be done (dressing changes, trach care, etc.)

I strongly encourage students to get in the patient's room ASAP. I find many "don't want to wake the patient" or find other reasons to delay getting in the room. This will get you behind. They must have vitals and assessments done before medications. I encourage this to be charted ASAP as well. I round early to find out the plan for each student and patient. After medications, I round again and can help students with other tasks.

However, I am very approachable and not the type of instructor you are describing. I have had disorganized students. I find it is a combination of delaying the start of work, saving all charting until the end, and talking too much (and often the patients LOVE this, but you have to strike a balance).

If you are taking a semester off, have you considered working as a CNA or tech?

onewill · Apr 2, 2013

Yes, I have decided to find a job as a CNA or tech. I think it would be good for me to get used to the hustle of a caseload. As for my clinical experience, we work with primary nurses that we depend upon to get meds out of a locked pixus for us...so I find that a fair amount of the time, this impaired my flow of care if they had other priorities with their other patients.

After report, I would wait for a computer to look up labs, admit. and hx, and care plan and plan it out on my brains. Daily weights, I/O's, q4h pain assessments, finding my primary nurse to get me patient meds, turning pts, glucose, insulin on pts due at the same time, etc. Bed baths and trash changes are done by auxiliary staff; however toileting/changing is our duty if we see it first.

I don't spend much time talking but I did find that charting on a new system I wasn't used to was pretty slow going. Also, getting used to a new hospital with new supply rooms and such also added on extra time so the beginning of my semester I wasn't a "hustler". The policy for giving meds is one hour before or one hour after the due time; however, I found that my clinical instructor was harsh with me if they were 15 minutes after the due time...so I felt pressured there, especially in a new med room and calculating and preparing IV push meds for the first time this semester.

When she pressured me, I once made an incorrect calculation. I felt I wasn't safe at the speed I was being pressured to achieve. New IV pumps...I needed help the first couple of times to operate, then after that I could do on my own but I wasn't quick with it; if I tried to go quickly, I would catch myself about to make a mistake (and my instructor was good at seeing the imminent mishap a second before I would!) and this all contributed to my instructor's sense that I was incompetent without her presence. Very demoralizing and it mentally got to me so that my natural learning became impeded by my fear.

Anyway, I do feel like I could have benefited and still can benefit from advice on how to tackle a caseload of 3 the first half of the semester, work up to 4 by the end of the semester and be ready for five for the final semester. I had 7 weeks under my belt this third semester which added up to 11 clinical days total so at least I will have that as I start fresh at the beginning of the same semester again...and definitely with a different clinical instructor that I mesh better with. I think my biggest challenge is seeing the whole picture of what each pt needs at what time and who to see and what to do first especially when they have things due at the same time. I am told that this takes experience to perfect; however, I was feeling pressure to achieve a competency level too quickly to be safe.

I have worked so hard to get this far that to think I could be weeded out because I'm not building that focus and organization as quickly as I am expected to (I DO believe I can get there) often wakes me up in the middle of the night. Like I said, Hopefully CNA experience will get me used to the hustle of a caseload.

Thanks so much for replying to me.

Tait, MSN, RN · Apr 2, 2013

I definitely agree that it is difficult to manage time flow when you have to wait for someone else, so figure that will get easier when you are on your own practicing. They have you taking five in nursing school? Wow, the most I ever had was two in my last clinicals. It wasn't until I was hired that I worked up to a full load.

There is discussion in a few new grad programs now that having a NG take five patients right away, however only given them one task to complete, such as doing all the assessments, is a better way of ramping up the responsibility.

When I had to repeat my management clinical I did much better with my second instructor. The way he described it was "Your last instructor set the bar up here and made you jump, I set the bar down her and help you reach higher and higher each time." He didn't mean it to degrade the previous instructor, only to show that different teaching styles work for different people, and he was spot on with me.

onewill · Apr 2, 2013

Well, we don't get 5 until we get into our fourth semester of the ADN program. In the first half of my 3rd semester, I was going from 2 to 3 patients at the time that I withdrew. It wasn't just the number of patients, I felt it was the deadlines throughout the shift that I was pressured to meet (in a safe manner). You make some good points and now I don't feel so self-denigrating about not meeting a bar that was set too high too soon for me. However, it will be the same way when I return: start at 2 at the beginning of the semester, work up to three then four...but hopefully I will get an instructor that is more like your second one.

I am interested in what other instructors might have to say about the expectation of working up to four for the third semester. Not having autonomy with retrieving meds and being unfamiliar with where supplies are on the different floors we get assigned to (we get a new floor every week or so) can sure hamper efficiency. Counting all actual clinical days in the semester, it amounts to 18 days on the floors.

Thanks for your response, Tait.

Tait, MSN, RN · Apr 2, 2013

Wait...so four patients and a new floor? To me these sounds like ridiculous expectations. I am curious as to what others would say as well. Maybe we should start a poll somewhere...

Tait, MSN, RN · Apr 2, 2013

Done and done.

daisy78 · Apr 2, 2013

I think the number of patients is dependent on how your clinical is set up with the hospital. I can never give students that many patients. (8 students x 4 patients = 32 patients) I cannot manage that many patients safely and the hospital I am in, the staff nurses do not "precept" or "mentor" the students. It is all on me to get meds done with my students. So that would not be safe. I would love if by the end of the semester, I could have students mentoring with a nurse and a full-assignment. But only if the nurse was truly mentoring. Sadly, I have yet to encounter a clinical situation where staff nurses were willing to do that.

I think you have unfortunately encountered a "perfect storm" of an intense nursing instructor, too many patients, and not enough support from the primary nurse (and I understand, they are very busy). Without knowing you and seeing you in action, it is hard to fully advise. It also sounds as though you do not get time to research your patients. We come in 45 minutes early so that students can access the computer and get their information.

Are you able to pull meds early and hold on to them (does your instructor give meds with you or the staff nurse?)?

Bouncyball · Apr 3, 2013

Hi,

I am in my final semester of an and program and taking 4 patients at clinicals. I assess, give all meds (but don't have access to the Pyxis) chart, call MD's and pharmacy, and transcribe all new orders. The only way I can get through the day is by staying organized. I always have one patient brain sheets and a pink, black, and green pen. I tried using brain sheets that had multiple pts per sheet but I would always run out of room. Here is a break down of my day:

Per facility policy, meds are usually due at 0900, and 1300 or 1400. They can be given one hour before and after. Assessments need to be done by ten and charted by 1100.

Clinical is from 7-3. I arrive at 6:15. Usually the assignment sheet is done by 6:30.

6:30- pick 4 pts all from the same nurse. Quickly find the kardex's and copy as much basic info as I can onto my brain sheets. This is usually just name, age, sex, admitting dx, previous dx, diet, activity, and allergies. If the night nurse I got the kardex's from is cooperative I will ask if anything out of the ordinary happened with these pts. Most of the time the night nurse will give me a mini report on them. Then I go to the computer and will quickly look up labs and only write down abnormal labs.

7:00- find the day nurse and listen in on report. Tell the nurse I need the MAR's. Most of the time they won't hand them over right away, but I at least look at them and write down the times the meds are due for each pt on their brain sheet in pink pen. I will also write done blood sugar checks and insulin in pink so it stands out.

7:30 (or when report is done and I looked at what times meds are due)- is the pt and iv check- grab a bunch of flushes and go to the pts rooms one by one. Wake them up if they are still sleeping. Introduce myself, check that iv is still good and has a date on it. Flush it if there is not fluid running. Check that tubing has a date on it. Do a 2 minute focused assessment on the pt ex: if they are there for pulmonary reasons, listen to their lungs and ask about SOB- that's it. Just make sure they are stable. If they are talkative dont get stuck there. Just politely tell them you just came to make sure they were not in distress and will ba back in a hour to talk to them. I also ask about pain level so I know if I need to bring back pain meds. I write the location and gauge of the iv site when I am in the room so I can chart on it later.

P

I try to spend no more than 5 minutes in each room at this time. After I'm done go chart one or two sentences in each chart stating the pt is stable and no signs of distress, ect. Check the charts for new orders.

0800- find the nurse, tell her the pts are stable and ask them to get the meds out for you. I grab one lab bag per pt and get all heir meds out at once. Each pts meds go in a separate bag with their room number written on it. I like to start with the most complicated/time consuming pts first. Start ASAP with the meds and get them all done one by one. I cross out the 0900 time in my brain sheet as i go. When I am giving meds to the last pt (usually 0915 or 0930 by this time) I wil also do my full head to toe assessment. I will write the assessment in my brain, then go chart that assessment. If anyone has insulin I will give it right away.

0930 ish- I will go do my assessments on my other three pts and write them on my brain sheets.

1000 ish- Sit down at the computer and copy my assessment from the brain sheets.

When I am done with charting assessments I will check for new orders again and read the doctor notes and do more research on the pt. if there is anything I need to look up or do gets written in green on my brain sheets. I am usually done charting and researching by 1100. If the pt has 1200 meds I will get these ready. If I don't have any meds due until 1300 I will take 5 minutes to eat my sandwich.

Then on to the afternoon meds and pt requests.

Usually it is just the morning that stresses me out. I still can get thrown off if I have a extra needs pt, if the meds are missing from the Pyxis, or if my patient is not doing well. I try my best to recover from those situations and save the rest of the day. I always make sure to keep the nurse informed, and ask them advice if you need it. Often, when multiple things come up at once I will tell them the situation and ask how to figure out what to do first. I am usually pretty lucky and as long as I keep the nurse well informed, they are usually pretty good about answering questions and giving advice. If they are not willing to help I will make a mental note and try not to pick their pts again.

I used to keep a written schedule for myself, but now I am able to do it in my head. As long as I can stay organized I am usually ok. If I start to get thrown off on time I will take ten minutes to myself, de stress, make a list of what to do in what order, and get to it. If your instructor is stressing you out or you are getting overly anxious when talking to them, tell them you need just a second to clear your brain, turn around take a few deep breaths and just keep going. I had the instructor from hell last semester and had to do this many times. If you feel like they a expecting more of you but not telling you make an appointment with them and talk about it. Find out exactly what they expect of you so you can give it to them.

It is very tough, but you can get through it. Just remain calm, organized, have a plan, and keep everyone informed. It's just a short period of time. School will soon be over and far behind you. Good luck, keep us updated.

Tait, MSN, RN · Apr 3, 2013

Thank you BSF for stopping by with your days layout :)