placed on Clinical Action plan...again (another long post--sorry)

[shining_star28463]

At the beginning of the semester in January, I was placed on a clincial action plan for my clinical performance. I did several labs on campus and wasn't allowed to go back to the clinical site until after spring break which was the second week of March. I worked really hard on my assessment skills and my patient care and I thought that I was doing really good until a couple of weeks ago when I got an "U" for time management skills and for not properly assessing the client during a 1st look and not getting my meds out before 10. After I got this "U", I was told that if I didn't improved by the next week (which was the week of April 9th). I would be placed on a clinical action plan again and possibly dismissed from the program. Well, the next week my CI said that I made incomplete first looks on my patients. I explained to my CI that I wasn't sure of what she wanted me to do on my first look because I hadn't been told and I'd basically been going into the client's room, looking at the client's position and assessing any fluids running and then going back later to do my head-to-toe assessments. She said that I should be doing a focused assessment during my first look. She also gave me a "U" for meds adminstration but she was the one pulling the meds from the Pyxis and when we got into the patients room to give the meds, she had missed two and had to go out and get them. She said this was my fault because it was my responsiblity to make sure that we'd gotten all of the meds even though she'd pulled the meds and was on the computer cart; not me. So, I took this all in stride and told myself that on the next clincial day, I would do better.

The next clincial day was the April 16th and I had no problems. However, on April 17th, that morning when I got report on one of my clients her IV rate was 150ml/h and when I went into her room the IV fluid was running at 100 ml/h. I assumed that maybe an order had changed or something and we hadn't been made aware yet and I charted the flow rate in my notes. That patient was placed on NPO which meant no morning oral meds but she did have a Lovenox sub-cut that needed to be adminstered. I went to do my assessment and care for my second patient and I got all of that done, then I went to the computer to look up my meds for adminstration.

A little background is that my CI has 6 students each with 2 patients and meds to give everyday which means there is bound to be some time issues, right? Well, I informed my CI at 0800 that my NPO patient had a Lovenox injection and that I was ready to give my po meds to my other patient. My CI zoomed off with other students, giving their meds and when it came time to give mine, the NPO patient had been transferred off the floor for a CT scan and the po patient had hers late.

I did my morning charting and went to check on my po patient who was getting ECG which I stayed and watched. By that time, my NPO patient was back on the floor and I asked my CI if we should give her meds. I had all of my drugs for her looked up besides 2 because I had sidetracked with the po patient. I told my CI all the info on the drugs and looked up the other 2 at the cart and with the Lovenox injection, I couldn't recall what was "special" about Lovenox and I had to go look it up (inject the bubble to seal the med) and after we got it out of the Pyxis, I had to figure the dosage (which I did). During that time, she zoomed off with another student and when she came back, I gave her all the info and prepared the injection. I had to waste some of the med and I asked my CI how I was going to waste the med if I couldn't get rid of the bubble. She said , "I don't know--you tell me. We're not going to give it until you figure it out." So, I stood there for about five minutes until I remembered that you hold the needle tip down so that the air bubble is at the top when you give it and then we went in to give the injection.

Today, she told me to meet her after class and said that she was placing me on a Clinical Action plan. She has written that I have poor time management skills because I didn't have 2 cards ready at the Pyxis and that I wasn't prepared to give the Lovenox injection (she stated that I had to return twice for additional info: (1) to give her the special instructions and the second time was the calculation that I had to figure). She said that even if she was on time, we wouldn't have gotten the Lovenox given out because it took me too long to figure out what I needed to do with it and that I disappeared and she didn't know where I was and I should have been looking up the 2 meds that I'd missed (in actuality I hadn't disappeared, I was with my other patient viewing the ECG) She also wrote that I improperly assessed the IV because even though I had it in my notes @ 100 ml/h, I should have questioned that it was incorrect because the Kardex (which isn't really up to date) and the chart (again, not really up to date) read the rate at 150 ml/h.

Today, during the meeting I did speak up and say I'd charted my info on the IV flow rate correctly and that even though it was a mistake to assume, I'd assumed that the doctor had changed the flow rate and the order hadn't come yet. I also stated she tried to make it seem like I wasn't doing anything when I was caring for my other patient and watching the ECG and that's the reason I didn't have the 2 meds looked up. I was told (with a really about analogy about my daughter climbing on monkey bars and the teacher not telling her to get down and that being an improper assessment of my daughter's monkey bar skills) that even though I charted correctly, I should have made my instructor aware of the discrepancy (which again, I shouldn't have assumed that the doctor had changed it but I am only a student and the doctor was in the room and I thought he had changed it and hadn't sent the order yet).

The issue that I have with being placed on a clinical action plan is that I feel like it is really extreme for the situation. I asked what the CI expected (as far as the first look is concerned) and then I implemented it afterwards. I try to get my meds given out and my charting done early. I charted my IV flow rate correctly. I asked the questions about Lovenox. I feel like I'm not being treated fairly. She states that I'm not making the connections necessary for a second semester student and that she doesn't know where my time goes (even though I chart where my time goes on my nurse's notes and in the computer) she worries that when I go into team nursing during the last semester which is a year from now, I'll be left behind because even though I do what I'm supposed to do, she is concerned that I don't know why I'm doing it and that if I don't pull it together in the 3 days left then I won't pass clinicals. I feel that being placed on a clincial action plan for this is unjust. I feel like just saying forget it and quitting.

I'm not playing a blame game here but I know that I've made great improvements in my care. I think that time management is something that comes with practice and I am also very tired of being the one that always gets called out and wrote up for some things that have to be learned and are out of my control. Anyway, I'm sorry this post is so long but I would appreciate some feedback. Thanks.

[Thedreamer]

Ouch. Sorry to hear youre having such a difficult time. I can understand where both you and the instructor are coming from. I do think shes being a tad tough on you, so you really need to buckle down and just show her you CAN do this, even to HER satisfaction. Youre still getting into the jive of things as a 2nd term.

Just remember, attention to detail can mean life or death sometimes. What if that was a K drip? Always check the orders or ask the nurse if you see a discrepency. I dont know what your policy is for medications but our clinical instructors are very down to earth about meds. We have 8 students on my floor with my instructor, all of them give meds. So if some of the students arent managing thier time well, she usually waits for them to be last

Solmetimes if she is spending too much time with them and they are taking too long to finish so the rest of us can give our meds, it is not unusual for some of us to simply say "we cant give these in a responsible time frame today since our instructor is currently busy with other students" and hand the meds back to the your preceptor. You cant be held responsible for being unable to give a med on time if the instructor is simply too busy to supervise you.

This is where nurse delegation comes in. You just need to realize how much time it will take you to do a certain action, or set of actions, and impliment the appropriate action. Time management is the bane of many of my co students at this point. Many of them dont do well under stress, but they WILL get better as the term progresses.

I hope you the best, and that you survive this clinical term! Just keep a good attitude and give it your all :)

[ukstudent]

You are probably not going to like what I have to say, but here goes. You do have time management problems. As a nurse you can't go off the floor and see the operation that one of your patients is getting just because it would be cool. You have work to do. As a student your work is doing your med cards. Watching the ECG was not something that you HAD to do, it was something that you WANTED to do. The med cards that your CI was upset about was something you HAD to do.

About the IV fluids and rate. Doctors are not trained on how to give fluids, they wouldn't know how to change the flow rate on the pump. If the doctor wanted the rate changed, there would be an order. If the chart said 150, the cardex said 150 and the pump said 100, then you have a problem. You need to use critical thinking and find out why the discrepancy and what needed to be done about it. People make mistakes, even other nurses. If you have a med order for 5 mg of something and the pharmacy sent 10mg by mistake, would you just give it because you assumed that a doctor had said something that wasn't charted? Iv fluids are like meds, you need to follow the rights.

If they allow you to continue, you need to reflect on what has happened and on how to improve. If you don't have a job as a tech at the moment I suggest you get one. It will help you with your time management. I do wish you the best and hope you become a great nurse. Talk to your CI and find out how to change and become one. Good luck.

[canoehead, BSN, RN]

The IV fluid was a serious problem. If the order says one thing and the pump says another that warrants immediate investigation. Check the chart, and then check with the nurse assigned to the patient, then if you aren't satisfied bring it to the attention of your instructor. If you had made the same assumption about another medication, the patient could have suffered serious consequences.

Five minutes figuring out how to give the lovenox....you weren't prepared. A day like that is forgiveable once, but if every day you are in clinical is like that I would have the same reservations the instructor has. You need to be johnny on the spot and ready. I agree with the previous poster that the EKG was nice, but if you had spent that time preparing for your med pass you would have been better off.

[maolin]

Shining star - I see from your post that you have great insight to your own situation - your description of the problems you are having reflect your accountability & maturity. I can see that you are trying to be objective in understanding this. I think that that will help you overcome this challenge.

While I know that it must be difficult and frustrating with this situation, I think you should remain open to your CI's feedback and develop an action plan so that you're on the same page as the CI and the expectations are clear. Some people just need a bit more time and/or space to get into the groove of things and for things to "click". I think you understand what your weaknesses are and are capable of making the necessary improvements. Sounds like the stress of the situation is magnifying the small stuff and you're already under close scrutiny. Don't let that get you down. Take a deep breath, think and then do. Hang in there! You're on the right track...make the most of the CI's feedback and put it to good use.

[Daytonite, BSN, RN]

remember, you asked for feedback and my writing tends to be more blunt and to the point than most although my intent is not mean (otherwise i wouldn't bother to answer you). . .your ci was correct in her assessment of you. i am not impressed with the attitude you are showing. if you are not willing to accept your faults as a student, i would be very worried to see how you would perform as a fully licensed nurse. i am bothered that you are finding excuses not to blame yourself for the mistakes you are making. that is an essential character flaw that could get you into serious trouble down the road as a licensed nurse. the evaluation of your clinical performance is about you, not the ci. you just aren't meet the standards that are expected of the students and you are fighting it. this is going to be a big problem for you all through the program, if you even make it through the entire program. it will also prove to be problem for you with employers. you have to follow rules whether you like it or not, period, end of discussion.

you made a couple of serious errors. (1) when you found the incorrect infusion rate on the iv, you should have gone to the doctor's orders to find the correct rate and resolved the discrepancy. an iv is a medical order. you never, n-e-v-e-r, never assume anything about a medical order. you actually used the word "assume" in your post which caught my attention right away. if the med sheet says the patient is to get 80mg of diovan and a 150mg pill is in the pyxis or med drawer, do you give the 150mg pill because that is what is there??? what kind of messed up thinking would that be? yet, that's about the same thing you did with that iv--you ignored it. that's not what i learned in nursing school. and, i don't think it's what you learned either. the way you handled that was a big time boo-boo. if you had been a licensed nurse that would have resulted in an incident report and possible disciplinary action for not doing something about it. (2) how do you waste medication from a syringe that has an air bubble in it? how do you give an injection with an air bubble in a syringe? if i had a student that didn't know how to administer an injection with a syringe that had an air bubble in it, i wouldn't permit them to give the medication, period. this is something that should have been learned in the nursing lab at school before even giving medications to patients. to allow a student to go any farther would be unsafe nursing practice.

i can forgive the time management problem because that does come with experience. fyi, the first thing is to get doctor's orders carried out (medications and treatments), and secondly, to work within the routine of the nursing unit. it might help you to make a list of the things you have to do and list them in priority before starting your clinical shift. (http://www.ehow.com/how_3812_make-list.html) all the time you must also be mindful of the patient's needs.

safe practice, however, is another story. you are very wrong to say that things are out of your control. i am talking about taking responsibility for your own actions. that may be your biggest problem of all. they are very much in your control. you need to be always asking yourself "why am i doing this" and "what should i be doing now". the needs of the patients always come first. when you aren't sure of things, ask others. not everything regarding time management and critical thinking are written down in books. however, if you display attitude and indicate that you aren't reading and learning the material, no one is going to want to help you. you have to be like an inquisitive little child, but pose your questions tactfully. and, if i were you i'd bone up on medication administration and the five rights. when you find something wrong as you did with the wrong infusion rate on the iv, you don't just ignore it. you bring it to someone's attention or you start asking questions yourself to get to the bottom of the mystery. rns are problem solvers. often the buck stops with them. you've got to be thinking on your feet all the time.

when you make an error you review in your mind what you should have done to avoid the error and correct your practice so that you are less likely to make the same mistake again. this is a characteristic called analytical ability. this is how you improve; this is how we all improved. that, and actual improvement as a result of it, is what your nursing instructors (and potential bosses) are going to be looking for. if you can't demonstrate that, then you and a career in nursing will be history. i think you know that this is probably your last chance. any further mistakes will most likely be a death blow to your career in this nursing program, so you have a lot of work to do. i was a manager. i know how this paper trail works.

quite honestly, unless you have some great epiphany and make some dramatic changes in your thinking and improvement in your performance i think your concerns for a nursing career are well-founded. you will have the same problems come up again and again over your lifetime, however, because of basic character flaws that i see in you based on what you've posted.

[AnnieOaklyRN, BSN, RN, EMT-P]

I am sorry you are going through this, but unfortunatly I agree with the other posters that you are having trouble with time managent. I am aslo a student and I think learning how to manage your time and best organize your patient care is difficult especially in the first couple of semesters, but you have to learn to do it and realize that even as a student when you have other priorities you cannot always go watch something that might interesting to you. I also agree with your instructor in that when you go an introduce yourself and check fluids you should be doing your head to toe assessment, that way if the patient goes sour you will have an idea of their baseline. This also helps in clustering activities so that you are not continously in your patient's room driving them crazy because patients need their alone time to and they hardly get that in the hospital as it is. Lastly you should double check meds that means check drug/dosage when you take them out matching them with the MAR, check them again at the bedside. If someone else gets them for you check them against the MAR once you have them just to make sure.

Try not to get to nervous because the more nervous you are the more mistakes happen.

Sweetooth

[srg4784]

Shining Star....if I didn't know any better...I'd say that this was one of my post from last semester...I definitely know where your coming from. I didn't question things (pt was CHF, cardex said regular diet...no fluid restrictions, no potty hat in toilet) I didn't question a thing...my time management skills were AWFUL i was usually the last person finished. Takes me 15-30 mins for a bed bath, and another 10-15 to make a bed. And please, don't let my CI ask me a question lol, I sure couldn't answer his questions. Ex...preceptor asked me "If your pt. Apical pulse was below 60 what would you do regarding this med" I answered..." I would get you"...The answer is, you wouldn't give that medication!!!...What made me so mad about that is I knew the answer in my head but I wasn't SURE it was the correct answer (meaning, I wasn't prepared). My very last day in clinical I was so excited that we had a foley to do ...Our facility was mainly rehab so we didn't get to do any procedures at all so I was excited and stepped up and begged to do it.....Knew I was going to do great b/c I practiced this more than anything.... Got in the room and didn't know diddly squat anymore "ummmm...can I touch this, what can I touch, is it ok to touch this?" I completely freaked out, so much that my CI just took everything from me and did it himself. I cried and cried because it was at that moment I knew that I was not a productive, prepared, or competent SN. I realized that if I didn't do something from that point on then, more than likely I'd never make it out of nursing school....So, the best thing I figured for me was more experience...so I now work as an extern. I've only been there for 3 weeks but I can just tell ya, my time management skills have improved so much...I'm less nervous and more confident. With the post above, remember they aren't being mean...just constructive criticism and I agree with them all...if it were up to me I wouldn't have passed my clincials last semester bc w my performance I don't think I was ready for the next level, but now I feel more comfortable. Go to your teacher, show them that you care. That is one thing my teacher loved about me. I was honest, when I made a mistake I woudl tell him and wouldn't leave until I was repremanded somehow with a learning experience, whether it be performing the skill over again or writing a paper lol. Remember, question everything that you are unsure about. The CHF pt. I told you about...not questioning those things put her at risk!!! Now when I see a CHF pt. you better believe that I remember those 3 key things!!!!! Good luck to you and let us know how your semester turns out!!!

[sshannon]

You are probably not going to like what I have to say, but here goes. You do have time management problems. As a nurse you can't go off the floor and see the operation that one of your patients is getting just because it would be cool. You have work to do. As a student your work is doing your med cards. Watching the ECG was not something that you HAD to do, it was something that you WANTED to do. The med cards that your CI was upset about was something you HAD to do.

About the IV fluids and rate. Doctors are not trained on how to give fluids, they wouldn't know how to change the flow rate on the pump. If the doctor wanted the rate changed, there would be an order. If the chart said 150, the cardex said 150 and the pump said 100, then you have a problem. You need to use critical thinking and find out why the discrepancy and what needed to be done about it. People make mistakes, even other nurses. If you have a med order for 5 mg of something and the pharmacy sent 10mg by mistake, would you just give it because you assumed that a doctor had said something that wasn't charted? Iv fluids are like meds, you need to follow the rights.

If they allow you to continue, you need to reflect on what has happened and on how to improve. If you don't have a job as a tech at the moment I suggest you get one. It will help you with your time management. I do wish you the best and hope you become a great nurse. Talk to your CI and find out how to change and become one. Good luck.

Have to agree with this poster's assessment. I hope your last few clinical days go well and you're able to demonstrate the level of skill they're looking for in a level 2 student. If not, and you have to repeat the level, just look at it as time to get better. Believe me, you'd be cursing your instructors if, as you move forward, you fall farther and farther behind and wind up failing the program. It's better to get a solid foundation at this point because it isn't going to get any easier. Trust me.

[kukukajoo, LPN]

I think if the doctor was in the room when you noticed the IV flow rate that you should have asked him then and there if he had changed it. This would have alleviated all problems on that one. Golden Rule: IF IT WASN"T CHARTED- IT WASN'T DONE.

I also see you being caught in a circle- you are behind your peers because you have not been on the floor as much and now don't understand the proper routines and what is expected. It just keeps getting worse the more that you are pulled off the floor until soon enough, your classmates are going to be leagues ahead of you.

I hope that you look inside yourself and see what needs to be changed and be willing to make those changes and that it is not too late for this year. If you want to succeed, you will find a way.

Also remember that the docs and nurses, aides- everyone on the floor- they are all great resources for your learning and anything that you have a question about. There is never a stupid question when it comes to the patient.

[shining_star28463]

As the OP, I think that I've been misunderstood in my first post. I never said that I don't take responsibility for my actions. As I was writing my post, I wrote objectively listing what I did and what my CI's response was, not as an excuse to blame anyone but so that all of the info would be available. I think it is very mean for someone to say that I have basic character flaws that will come up over and over again because (1) as far as the IV rate is concerned, I understand it was my error and I take responsibilty for that error. I stated that I did chart the infusion rate @ 100 ml in my notes but it was a mistake not to inform the nurse or CI of the discrepancy. I said as much at the meeting that I had with my CI and I also said that it was wrong of me assume that the doctor had changed the order. The Kardex and pt charts on the floor are notoriously out of date. The CI has even commented on this. But I should have said something. I know this. That was a mistake that won't happen again.

(2) With the medication administration, I understand that I should have had the final two meds looked up and with the Lovenox injection; as a student with lots of information floating around in my brain sometimes it takes a while to sort out the right information. I had never given a Lovenox injection before and with the air bubble; after I figured out what I needed to do I felt like an idiot for having to take that long to figure it out. But I look @ it as a learning experience and now I'll never forget how to give a Lovenox injection.

(3) With the first look, I wasn't sure of how my CI wanted her first looks assessed, so on the 10th before I did my patient care, I asked her. She asked me what I thought I should do and I told her how I had been doing my first looks previously which basically consisted of assessment of IV fluids, patient position in the bed and IV site condition and then going back later and doing a head to toe assessment. This is my previous CI instructed and different CIs have different expectations. She told me to do a focused assessment for my first look, which since then I've implemented in my care.

I'm not blaming anyone else for what I need to improve on and I'm trying to blame anyone. As far as the time management is concerned, I am working on my time management skills, I try to keep myself on a tight schedule. I didn't seek out the patient to view the ECG because I thought it was interesting. I wasn't even aware that she was having an ECG done because the MD had just ordered it and when I went in to give my afternoon care the tech was there doing the ECG. I understand that I should not have stayed and watched and the 2 drug cards that I was missing was more important.

I don't fault my CI for anything and I do take responsibility for my actions. When I say that things are out my control what I am saying is that if I am ready to give my meds @ 0830 and my CI is with another student and I don't give my meds until 1000 because she has to get the meds out, then that is out of my control. I am also saying that when I ask a question about something that I am unsure of and the answer is "you're the nurse, you figure it out," it makes me feel like I shouldn't be asking questions. I'm not asking for anyone to hold my hand or to baby me but I believe that it's forgotten that I am a student...I am learning and I am trying.

[WDWpixieRN, RN]

When I say that things are out my control what I am saying is that if I am ready to give my meds @ 0830 and my CI is with another student and I don't give my meds until 1000 because she has to get the meds out, then that is out of my control.

I can empathize with this statement as it has happened often in my 2 semesters of school....our CI last semester didn't seem capable of dealing with more than 3 or 4 of us at at time, and as a student, it was quite frustrating. For the poster who mentioned telling the preceptor about the inability to give drugs due to your instructor being busy -- that's probably not always a good option when you have an instructor that hasn't given you that direction. I can see some of these drill sergeants thinking it's a reflection on their capabilities and biting heads off. I don't agree with that action, but sometimes it's just hard being the student caught in between!!

I am also saying that when I ask a question about something that I am unsure of and the answer is "you're the nurse, you figure it out," it makes me feel like I shouldn't be asking questions. I'm not asking for anyone to hold my hand or to baby me but I believe that it's forgotten that I am a student.

Wow, shades of last semester for me...I honestly thought I should just give up nursing as my instructor seemed to think I was a cardio and lung specialist and should know every sound my pt was making one day after 4 weeks of clinicals. I wanted to cry when she jumped down my throat for asking her help me discern what I was hearing. It's not easy when you have an instructor who isn't easy to approach.

Best wishes to you....just know that things will work out for the best in the end....