Students, RNs and medication admin - Is this crossing boundaries?

[Apples&Oranges]

I am a first year first semester nursing student. I have been in clinical for 11 weeks. We started passing meds 3 weeks ago. Our clinical group has 8 students an our instructor has been dividing the group in half for passing meds - as in 4 students get to pass this week and 4 the next. I completely understand this, as she does not have time to supervise all 8 of us in the act of scanning wristbands, verifying barcodes and dosages, etc. for all 8 pts before 9am for 8am meds. My question is, as I have (I believe) proven myself to be a reliable student so far (I understand and can explain my patient's diagnosis, the classification, action, side effects, etc of all drugs,) would it be presumptuous of me to either my instructor or, more importantly, the assigned nurse, to ask if the nurse could supervise me giving meds? Rather than my instructor? If you are a nurse, would this make you uncomfortable since I am only first semester? If you are an instructor would this worry you because you are "responsible" for me? Thanks for the input, don't know the politics and don't want to step on anyone's toes...

[akulahawkRN, ADN, RN, EMT-P]

I'm a current student... just not 1st semester. In 1st, you pretty much work entirely under the direct supervision of the clinical instructor. After 1st Semester, we're checked off on PO med pass with our clinical instructors and can usually do PO meds on our own. Certainly this is the case with 3rd Semester students. As long as I'm familiar with the meds, I can give them. We still have to have an RN or Instructor with us when we do anything except rate verification of IV lines or inject a medication. Next Semester, we'll do IV push meds and the like, and toward the end, we'll do pretty much everything.

Don't worry, there's lots to learn and a reason why your school does what it does. (Med error prevention!!!!!)

When you say "PO meds on your own," do you mean give them after the instructor has reviewed them/labs/VS/NPO status/etc. with you, or do you mean that you check the MAR and just give whatever is scheduled on your own without any supervision?

If it's the latter, hrm. I, as the nurse responsible for the patient, wouldn't like that. At all.

In 2nd and 3rd Semesters, we do review with our instructors those things for check-off. We're also required to write up every med that our patients have ordered as part of our prep. This is so we know what we're giving, why, and what to watch out for, including relevant labs. We do let our supervising nurses know what we're doing so they know what's going on, but we are not required to have someone observing each and every time we give PO meds. If the supervising RN wants to, that's perfectly fine. We actually do a lot of communicating with the nurses we're assigned to, so they're really not unaware. At one facility, we're the only program allowed to pass meds to patients. This includes the local BSN program.

And yes, there have been many times that I've held a med because it was inappropriate to give. I notify the nurse I'm working with about it and why so that med isn't inadvertently given by someone else.

We have access to the Pyxis systems and can pull most meds on our own. If we're not familiar with a med, we can't give it. We're expected to look up unfamiliar meds before we give them. While it is uncommon for us to give meds to a patient that we're not assigned to, we look up any unfamiliar meds, check any relevant labs for that patient, and notify our instructor what we're doing for approval to give those meds. We're not entirely unsupervised, however the level of supervision for 3rd Semester students to give PO meds is a lot different than it is for 1st Semester students. Even in our program, I would be VERY uncomfortable with 1st Semester students giving meds at the current level of supervision I have right now.

And this also is what has been agreed to with all the hospitals we go to, and my program.

[BuckyBadgerRN, ASN, RN]

In my school the INSTRUCTOR decided when a student was ready to be "released" from her watchful eye to the RN on the floor IF that RN wanted the responsibility. It is certainly never up to a student to decide that they are knowledgeable of ALL drugs that a patient might be receiving.

[RED1984, BSN, RN, EMT-P]

In our program, we do validations in Lab practice and have to pass. Then, at clinical rotations, our instructor "checks us off" once and we are able to pass meds from that point on- usually under direct supervision of your assigned RN. Some RNs have more trust in you and let you pass meds without them in the room, but some directly supervise. When I become an RN I'd personally directly supervise.....

[evolvingrn, BSN, RN]

a lot of the students that come to us don't know the medications when we ask them questions.....an instructor should be supervising them so they can assess that knowledge or lack of.....

[Kooky Korky, BSN, RN]

I haven't in school for a looooooong time, but I do remember that our Instructors quizzed us up one side and down the other on our meds.

I also recall that staff nurses, who were ultimately responsible for students' patients, could approve us giving meds. But the meds were those on which we'd already been quizzed and had already given. It's really not fair to expect the staff nurses to do the Instructors' job.

It's hard but be pt and follow the rules.

[Wrench Party]

Depended on the instructor, the patient population and the semester. I was supervised on all meds by the instructor in my peds rotation because we had some really sick kids. However, in my senior capstone clinical, the precepting staff nurse let me 'have at it' with all kinds of meds, the exception being the high alert ones like insulin.

[JustBeachyNurse, LPN]

I think the biggest distinction is a first semester student on first med pass vs 2nd/3rd/4th year student who has demonstrated competence & reliability. I doubt there are many schools that permit first semester students do their first med pass with anyone other than a school clinical instructor. Responsibility & independence increases with time & demonstrated competence. Just like confidence increases over time.

[akulahawkRN, ADN, RN, EMT-P]

Depended on the instructor, the patient population and the semester. I was supervised on all meds by the instructor in my peds rotation because we had some really sick kids. However, in my senior capstone clinical, the precepting staff nurse let me 'have at it' with all kinds of meds, the exception being the high alert ones like insulin.

Regardless of semester, in my program, all med passes to pediatric patients are supervised directly by either the instructor or the primary RN for that patient. Pediatrics used to be in 3rd Semester, now it's in 2nd. There were a number of reasons why that content was moved to 2nd Semester, but one of them was probably that it throws off 3rd Semester student confidence when they have to be 100% supervised for med passes in that rotation. Since this is more normal in 2nd Semester, to have closer supervision, it does make sense to put Peds in that Semester. The other reason for doing this is to give the 3rd Semester students more time at an elevated scope of practice, and some increased independence.

[akulahawkRN, ADN, RN, EMT-P]

I think the biggest distinction is a first semester student on first med pass vs 2nd/3rd/4th year student who has demonstrated competence & reliability. I doubt there are many schools that permit first semester students do their first med pass with anyone other than a school clinical instructor. Responsibility & independence increases with time & demonstrated competence. Just like confidence increases over time.

This is why we're allowed to give meds the way we do in 3rd Semester. We've demonstrated competence, and earned the responsibility to have the independence that we've been given. We all know we're not quite ready to to be RNs, but we know that we'll be ready to step up to 4th Semester and take on that role when we get there. We all also know that if we do wrong, then we mess (put kindly) things up for not only the rest of us, but those behind us as well. One skill that was taken away from all students (for some reason) was doing BGL checks. I doubt it was a student from my school, but one bad experience by a hospital and everybody loses.

[Apples&Oranges]

Thank you all so much for your comments and different points of view. We have many different university's students on our floor at different stages in their training. Some are 4th year, some have only been on the floor for two weeks. The RNs, at times, understandably get confused as to who should be doing what. Occasionally, the "nurse" to whom I was to report was actually a 7th semester student nurse! Talk about confusing roles.... When I am asked to do something that is CLEARLY out of my scope of experience (this week I was asked by a phlebotomist if I could "real quick" get some blood for her since she was running behind...Um, no?) then I clearly refuse. Med admin can be tricky. Thank you all for your input, I'm sure many students, especially those on a mixed floor like mine are apprehensive about the politics of this issue.

[Naturalist]

Yes, it would be presumptuous of you to expect to give meds without your instructor as a first semester nursing student. A staff nurse will supervise you in order to establish competency, as your Preceptor, when you're in your final semester of school, never to babysit when you're in first semester. That's your instructor's job, and trust me, she wouldn't have it any other way.

It's not politics. It's policy and procedure, and it should be clearly outlined in your Clinical Guidelines book. You should know it well. If you demonstrate the opposite, it may raise a red flag that you have the potential to be unsafe.

Don't rush. Take your time, and enjoy the journey.

[Kaltia]

I rarely recall giving meds unsupervised as a student. Even with a preceptor,, especially if you weren't drilled backwards and forwards on each of those meds ahead time. After first semester, you could within reason do whatever the staff nurses were willing to supervise. While I certainly never was unaccompanied, the staff nurses would often let me tag along with them and would go over what they were doing. I got to draw up IV push meds, insulin and so on even though I usually didn't give them without my instructor. however while I did this stuff, the staff nurse was there saw the whole process and always double checked my work. It varied with clinical instructors some were very strict about not doing anything med wise without them. Others were more relaxed.

Also as a student, I rarely had pixis acess, usually you gave meds with your instructor or the staff simply because you couldn't give them any other way. So the whole issue was a mute point. 4 students doing med passes especially first semester is alot. 2 at most is what I recall from each clinical day even for 2nd semester.

As the staff nurse, students are a mixed bag. I always try to provide opportunities for them and I will let them help with meds, but anything they give is done with me in the room supervising, unless their insturctor is in there. I do think it would help if nursing schools would at least regionally get guidelines together for different levels of students. my floor gets students from 4 different schools everything from 101, to precepting match ups and I never know who is doing what.