Out of touch clinical instructor

[Nurseboy1]

I am currently working with a senior nursing student from an area university. The student follows my schedule working in the MICU of a large academic medical center. Our patients are high acuity and we are pretty busy for the most part.

The clinical instructor just doesn't seem to get it. She has came to the unit on several occasions when I have had VERY sick assignments, working hard to keep the patient alive wanting me to let the student have more responsibility. Such as titrating the pressors or pushing code drugs.

Am I way off base here, but generally I view the crashing sick patient as a little too acute for a student. There are lots of rules we are given by the university including restrictions on what the student can't do, and typically common ICU interventions (such as CO shooting, A-line draws, titrating vasoactives, etc) are on the do not perform list. The instructor even called my manager to complain (luckily my manager dismissed the complaint). Am I being too restrictive on the student's practice or is the instructor just too far removed from the bedside to get it?

[caliotter3]

This should be left to your discretion. If you feel comfortable standing by while the student does something, watching every move and giving total supervision, that is your call. The clinical instructor should stay out of it unless she is going to supervise the student. We were provided a list of do not do procedures. Very disappointing to the students. Our preceptors, for the most part, allowed us to do procedures as they came up. But they supervised us.

[llg, PhD, RN]

Is there a way to allow the student to "participate" or "practice" without actually turning over the care to her? For example, if there is something to be calculated, could you and the student calculate it separately and then compare answers? Or could you ask the student what she would do in this situation? In each case, it would be YOUR judgment used to determine the care, but the student would have the opportunity to practice making the judgment.

There is no reason a student couldn't practice titrating vasopressors -- as long as you were simultaneously doing the same assessments, calcuations, etc.. -- and the student were not actually changing anything with the patient unless you agreed.

I coordinate a lot of student clinical experiences for my hospital (and am a former NICU nurse). I have found that some preceptors see things as either "letting the student do it" or "doing it themselves" as if there were no choices that are in between those 2 extremes. Perhaps if you talked with some very experienced preceptors, a clinical nurse specialist, or a staff development educator ... you could find some ways to find that "happy medium" between the two extremes.

My hospital allows students doing in-depth preceptors to do almost anything a nurse does -- as long as the nurse preceptor is physically at the bedside and they are doing it together. That way, it is the RN whose judgment is guiding the activity while the student gets to touch, see, etc. and practice making those judgments with someone "at her elbow" to keep the patient safe.

[lifetimern]

I, too, agree that you should determine the boundaries of your student's practice. However, is this experience just another clinical for the student or is this his clinical preceptorship? During regular clinicals, students often function under tightlly regimented constraints like the ones the OP described. But, during a capstone preceptorship, nursing students who are about to graduate work with a single nurse/mentor for a longer time period. The goal of these preceptorships is to aid the nursing student in their transition to the R.N. role. By the end of the preceptorship, the goal is for the student to be functioning as closely as possible to the actual role of the R.N. Ideally, the preceptorship begins with the task oriented and externally directed student progressing to a critically thinking, internally driven, and functional "nurse" under your leadership. This form of clinical is fairly new; it is often unfamiliar to many experienced nurses even though it resembles the model used in medical schools and residencies for generations.

If you feel the student lacks the knowledge or skill to function in your environment, perhaps, this lack of progress is what should be addressed with his clinical instructor. If, on the other hand, the student has demonstrated a novice level of understanding and ability, you should try to increase his level of responsibility. Now, I'm not saying you go sit down while he takes care of the multi-sytem trauma patient on a roto-prone who is circling the drain, but you have to allow him to push his boundaries to find where his limits are.

[Nurseboy1]

My hospital allows students doing in-depth preceptors to do almost anything a nurse does -- as long as the nurse preceptor is physically at the bedside and they are doing it together. That way, it is the RN whose judgment is guiding the activity while the student gets to touch, see, etc. and practice making those judgments with someone "at her elbow" to keep the patient safe.

This is typically how I work with students. This is not my first student and I have precepted multiple students from several area schools in addition to new nurses on the unit. I guess when the patient is going down the crapper I don't take the time to teach, I act to help the patient and teach later, maybe that is something that I need to adjust. I am just really floored by the instructor, I generally receive positive evals from students, this is the first time an instructor has complained. I am really amazed that she would not talk to me, but rather call my manager.

The NC BON kind of muddies the water with skills. Several skills like arterial punctures and swan numbers are on a list that require documented competency to perform. So for me to allow a student to perform these skills violates the BON and if they mess up or cause unintentional harm I don't have a legal leg to stand on.

[caliotter3]

When she talked to your manager instead of speaking to you she showed that she has a problem with seeing you as an equal professional. Her opinion of herself must be very high that she thinks she can only discuss things on the "manager" to "manager" level. I feel sorry for the students that are in her clinical group. I doubt they benefit much from her expertise since she doesn't want to talk to anyone "below" her.

[netglow, ASN, RN]

IMHO, OP you are correct

I don't think you are required to take on that kind of burden with your student. I'd look at it this way: It seems you've allowed them to participate to an incredible extent already. I was grateful for what I learned in my time in the ICU. Seriously, doing a student gig in the ICU can never be one where the student takes full control like you might on a medsurg floor. There is just too much at stake and the learning curve is too high.

Also, some instructors like to try to "appear" important by making ridiculous comments to nursing staff when onsite. I had one like this. I don't think she had worked in hospital for many years! In acknowledging the inappropriateness of her comments, I'd just find a moment to lock eyes with my RN, and then roll my eyes to let my RN know, that I knew my instructor was out of line.