Starting clinicals - Question

Here.I.Stand, BSN, RN · Jan 16, 2017

In my nursing school days (early 2000s), it was the clinical instructor who instructed us clinically. Reading posts on here, it seems like turfing his/her job to the floor RN is becoming common. I agree with you completely -- it's foolishness. 1) the floor nurse is paid nothing to do your CI's job, 2) the school hasn't vetted floor RNs to insure that you are getting quality education from them, 3) the patients don't need their nurse slowed down, 4) why the heck is your CI getting paid to not teach......... yeah I don't like this idea.

Your attitude sounds ideal, though. You recognize that your presence at the floor nurse's side doesn't help her/him (not your fault -- it just is what it is.) You are humble and appreciative of the nurse's time, rather than indignant that that nurse OWES you their time, after all they were once a student too.

Personally I like teaching students. I haven't had many because I work in an ICU where a few students a year are placed for their senior practicum and work with one RN. On a couple of occasions the RN was either sent home for low census or got sick, so I filled in. Years ago when I worked in a SNF I had a handful of LPN students with me for their practicum; here and there we'd get a class on the floor doing a regular clinical shift. But in some settings yes it can be difficult to fit anything else into a shift where we may be swamped with patient care.

I'd encourage you to direct as many questions as you can toward your CI, research them yourself if you can, etc rather than pepper the RN with questions. Help answer call lights, help with ADLs where you can that kind of thing to help lighten the staff's load. And thank the RN for his/her time. :)

taivin · Jan 16, 2017

Hi; good for you on the 4.GPA. As far as clinical protocol, it all depends on the school. I was in a BSN program and we started in LTC. Also at every clinical we had to develop our own care plans after picking out patients in the facilities we were at; nursing Dx and theory. Our instructors just were around but expected us to take the reins. The RN your quote unquote "assigned to" is the lead person in my program. This is important, not all RNs want to be saddled with a nursing student. Then there's the instructor themselves. It can be a challenge.

I'll never forget my first resident (in LTC), my first clinical, I had a diabetic and there was a sliding scale. The RN I had was gone. I went to my instructor and asked her what the extra orders meant under the sliding scale and showed it to her. She told me to do nothing. When I saw my RN I alerted her to the sliding scale and I left. The next day my instructor was pulled into their DON's office. I don't now what happened, but always look for that sliding scale coverage with diabetic clients. Now decades later, I have to wonder how much experience the clinical instructor had and if I had smart phone back then, I could have looked it up.

We were taught from the ground up with transfers, feeding, wound care, etc... you find all that in LTC/SNF or med surg. Keep an open mind, there are no stupid questions, and for God's sake if you don't know, say so. Stay above the fray and learn as much as you can. Let us know how it goes. Don't let the nurses know you're a 4.GPA, I was as well...

Keep your pharm book with you, and don't give any medication you don't know what it is, why it's being given to your patient and why and how it works for the Dx you are administering the med for. Route, correct identification of med and amount. Find out how they take their meds and check 3x before giving. Is it a new med, etc... you should know the drill. Who, what, where, when, why and how much...always check hand IDs, if no ID like in LTC, ask staff to identify them for you. If possible, look at the original order. Here comes the big one...if they can do it themselves, let them.

The nurses who took students were paid extra...I don't know how much but it was in their union rule book. Unions forever!

Good luck!

TheCommuter, BSN, RN · Jan 16, 2017

Moved to the General Student forum for more replies.

lunanarya, BSN, RN · Jan 16, 2017

In our program, our instructor is our go-to. They're ultimately responsible for our actions as students; we're working under their license while at a site. We're encouraged to trust and rely on the floor nurses wherever we are working, as it helps build our communication and team work skills.

As far as a day-to-day...Usually our instructor will post a patient assignment at the facility on the day before a rotation. If it's a brand new facility, we get the assignment the morning of rotation, along with a brief tour on how/where/when to find everything and access the facility's records. If it's a facility we've been to before (like right now we're doing lots of long-term care,) we're responsible for going to the facility on our own time the day before, meeting the patient, gathering data, and coming up with a diagnosis and care plan. Then the morning of the rotation, we have a pre-conference with our instructor to go over our plans, then attend report with the floor nurse working with the patient. Sometimes we have to edit our plans depending on what the nurse has going on. It can be crazy. But every one I've worked with so far has been really great. Then we get to work. Our instructor is available to answer our questions, help, and supervise certain things like patient transfers. Then we meet for a post conference to discuss any issues and go home and write our voluminous reports.

AliNajaCat · Jan 16, 2017

They're ultimately responsible for our actions as students; we're working under their license while at a site

No, no, a thousand times no. Students do not "work under" somebody else's license, whether it's a clinical instructor or a preceptor. Students are legal adults and work under their own scope of practice, that of a student of ABC College, which they are required to know. The limits of their scope depend on the school's policies, their contract with the host institution, and the institution's policies.

If, for example, your school policy is that no student will ever administer a vasoactive drug intravenously, it doesn't matter if the Director of Nursing hands you the syringe and says, "It's OK, honey, go ahead and give it, I'm right here." You DO NOT DO IT. If hospital policy says that no student will perform nasotracheal suction on an infant less than age 2, you DO NOT DO IT.

If something goes wrong, you are not absolved of responsibility because you exceeded student scope of practice while working with an RN (your instructor or a preceptor). The RN is in her own hot water, as she should know (because you tell her) that doing this is outside your scope of practice, but you are still in trouble for doing it when you knew better or ought to have known better.

NICUismylife, ADN, BSN, RN · Jan 16, 2017

It depends on the school. For med-surg, we were always assigned a patient, and we did total care for that patient during the shift under the supervision of our instructors, including speaking with the doctor when he made rounds. Aside from the nurse's initial assessments, I usually didn't see the nurse again unless I had to report a change in status, have a doctor called, etc. Our instructor could pull meds and such, so we did med passes with the instructor. If a new order came through, the nurse would just hand it to us, and we'd do it. Like a pp mentioned, the instructor would post an assignment list the day prior, and we would go in the night before to gather patient info, then we'd go home, research the dx, look up all the meds, and put together a care plan for the next day (all of this could easily take 4-6 hours). We were allowed to keep the same patient for both clinical days though, but if the patient went home, we'd have to do it all over again for the new patient we were assigned.

For ICU (4th semester), we were considered to be more autonomous, so we went in blind, got our assignments that morning and precepted with a nurse. All the nurses we were assigned to were specifically chosen (there were some that the instructors wouldn't allow us to work with for varying reasons). The instructors allowed us to pass meds with the nurse, perform all skills independently, and work alongside the nurse. Those nurses were super helpful. Every single one of them educated me every day. And I learned so much from watching how they managed their time, organized their patient load, etc. They were great about allowing us to "be the nurse" each day under their supervision. The instructor was always on the floor all day though, and if we wanted additional information or help, she was always available. Most days, there would be something I would pull her aside for, like have her go over how to check a wedge pressure, have her watch me zero out an art line to be sure I was doing it correctly, etc.

emmjayy, BSN, RN · Jan 17, 2017

I'm sure it depends on the hospital/program. At my school, the instructor did the teaching. Day before clinical, the instructor would assign patients to us and we would write our care plan. On clinical, we provided as much care as we were qualified to give to the patients - since it was first semester we did vitals, head to toe assessment, breakfast, OOB if possible, bath, toileting, I&O's, complete bed change, meds, charting, and answering call bells. We would report to the RN in charge of our patient if we saw something unusual/weren't sure what to do and couldn't find our instructor. However, our first line of defense in the face of things we were ignorant about was our instructor!

LessValuableNinja · Jan 17, 2017

No, no, a thousand times no. Students do not "work under" somebody else's license, whether it's a clinical instructor or a preceptor. Students are legal adults and work under their own scope of practice, that of a student of ABC College, which they are required to know. The limits of their scope depend on the school's policies, their contract with the host institution, and the institution's policies.
If, for example, your school policy is that no student will ever administer a vasoactive drug intravenously, it doesn't matter if the Director of Nursing hands you the syringe and says, "It's OK, honey, go ahead and give it, I'm right here." You DO NOT DO IT. If hospital policy says that no student will perform nasotracheal suction on an infant less than age 2, you DO NOT DO IT.
If something goes wrong, you are not absolved of responsibility because you exceeded student scope of practice while working with an RN (your instructor or a preceptor). The RN is in her own hot water, as she should know (because you tell her) that doing this is outside your scope of practice, but you are still in trouble for doing it when you knew better or ought to have known better.

This is false in Texas.

NicuGal, MSN, RN · Jan 17, 2017

All of our procedures have a chart as to who can do what and if it has to be supervised. Be very familiar with policy and procedure.

ICU_UcMe, BSN, RN · Jan 17, 2017

If something goes wrong, you are not absolved of responsibility because you exceeded student scope of practice while working with an RN (your instructor or a preceptor). The RN is in her own hot water, as she should know (because you tell her) that doing this is outside your scope of practice, but you are still in trouble for doing it when you knew better or ought to have known better.

Fact. I got screamed at my first semester of nursing school because I refused to take an order from a doctor. Umm, let's see, I had been in nursing school for a matter of weeks, and I was specifically told it was out of my scope of practice so why would I do that again? If I had done it, my clinical instructor wouldn't have been in trouble-- I would. I am the one who knew I wasn't supposed to.

On another note, I told my nurse about it after the fact, and she went and yelled right back at him. In her words, "you go apologize to that young lady right now because YOU KNOW BETTER!" He came and apologized too. It was the funniest thing I had ever seen.

AliNajaCat · Jan 17, 2017

This is false in Texas.

Citation from the relevant regulation, please. Even TX should know better than that.

I know of no NPA (nurse practice act) that allows an RN to delegate RN practice to an unlicensed person except as part of a duly authorized student program. BoNs know that students need to practice; that's why they're in school.

However, even that does not constitute the student "practicing under somebody else's license." And yes, it does make a difference.