Problem Students

VickyRN, MSN, DNP, RN

Melissa was the type of student that educators dread. She did not take responsibility for her choices, always had an excuse for her inappropriate actions, was manipulative, dramatic, and histrionic, and sincerely believed that the clearly-stated rules should apply to everyone but her. It didn't take long for a troubling pattern of behavior to surface.

On the first day of clinical orientation, Melissa was a "no show." She claimed she never received the e-mail memo detailing the instructions for the first clinical day. On the second day of clinical, she was 10 minutes late to the clinical site and "forgot" to remove her nose stud jewelry. During the third clinical day, Melissa was found texting on her smart phone, rather than taking care of her assigned patient. When quizzed by the instructor at the medication cart later that day, Melissa was unable to give the safe dosages, reasons, possible side effects, and precautions for her assigned patient's medications. Fed up, the instructor sent the wayward student home. To make matters worse, her clinical paperwork was shoddy in quality and often turned in late. By the fourth clinical day, Melissa had been suspended from the nursing program for numerous violations of school policy.

Clearly, Melissa did not put forth the necessary effort to learn, nor did she conform to the rules of the program. The sad result was an enormous waste of taxpayer money and inefficient use of scarce educational resources. Her seat in the nursing program and the opportunity for a marvelous career and brighter future, which another applicant could have used, was squandered. Melissa's disruptive behavior deprived the other students in the clinical group of positive learning experiences. Even worse, her lack of preparation and lackadaisical attitude made her unsafe to care for vulnerable patients on the unit. Melissa was ultimately dismissed from the nursing program, but only after a long arduous appeals process during which she tearfully accused the instructor of being "mean," "a terrible teacher," and "always picking on me."

Dealing with manipulative, careless, and recalcitrant students like Melissa can be wearisome and demoralizing, especially for a novice instructor.

What, then, is the best way to handle "problem" behavior in students?

First and foremost, KNOW your nursing program's policies and procedures. Then, carefully and consistently FOLLOW them.
Make sure all expectations are clearly communicated to the students in writing. The syllabus is the official contract between the educator and individuals enrolled in the course. Expectations for learners, along with consequences for unacceptable behavior, need to be meticulously spelled out. There should be a clause in the syllabus to remind students that they are responsible to follow the guidelines in the Student Handbook, including requirements for patient care and stipulations for professional behavior on the clinical floor.
Be proactive and not reactive. Deal with objectionable behavior early on ("nip it in the bud"), rather than simply ignoring it. Problematic behavior, if left unattended, only tends to get worse, and it can spread to others in the group. On the other hand, if such behavior is addressed early, it sometimes can be successfully remediated.
Patient safety is paramount and should never be compromised. If a student is unprepared or careless, then immediately remove the student from the clinical area.
Take care to only address the specific behavior and explain why it is unacceptable; never attack the person. Stay on target and do not digress into irrelevant matters. Never devalue, demean, or threaten the individual or use derogatory terms. Instead, calmly and factually spell out the consequences of the student's problematic behavior, should such behavior persist.
Discuss strategies the student could use to be successful. At the same time, emphasize that the student, as an adult learner, is ultimately responsible for his or her own learning and this requires total commitment on his or her part. No one can do the learning for the student. This emphasis on personal accountability flies in the face of the "victim" mentality so prevalent in contemporary society.
Always be objective, calm, and consistent. Do not allow emotions to cloud your judgment.
Model professional behavior at all times and cultivate an atmosphere of mutual respect.
Avoid favoritism at all costs. What applies to one student should apply to all students.
And last, but certainly not least - document, document, document! Keep a detailed paper trail of your interactions with the student. The paperwork is irrefutable proof of attempts at remediation and retention, as well as student acknowledgment of the disciplinary process. The detailed record will also substantially increase your chances of successfully defending your actions in an appeals process or court of law, should it come to that. Learning contracts are a marvelous tool for this type of documentation. For your convenience, I have attached two learning contract templates that I have used over the years with positive outcomes.

Thankfully, the vast majority of nursing students are respectful and professional people who are motivated to learn, do their best to care for their assigned patients, and are a joy to teach. Occasionally, however, there is that one student from Hades who consumes a disproportionate amount of an instructor's time and energy, is disruptive, and wields considerable negative influence within the clinical group or classroom.

What have been your experiences in dealing with "problem" students such as Melissa? What strategies have you found to be most effective?

Learning Contract.doc

Student Conference Notes.doc