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  1. Have you ever been to Disneyland? I know. What does Disneyland have to do with clinicals? I enjoy going to Disneyland and have always been impressed with the excellent customer service that one will experience there. At Disneyland, all employees are "on stage" when they are out on the grounds, always performing, if you will, for the customers. It doesn't matter if they work as a janitor, work at the snack bar, or as one of the characters. All employees that are in the public eye are "on stage". How can you use this information to help you as a nursing student? By remembering that when you are in clinicals, you are on stage. This is your time to shine. This is your time to be a team player and work alongside the staff to help the patients, while you are learning and going through clinicals. When I was in my last quarter of nursing school, I was on a telemetry unit. I already knew the above information and used this to my advantage. I worked hard and helped the nurses and CNAs when possible. I tried to go the extra mile and show that I wanted to be the best nurse I could be and that I was teachable. I was fortunate to be hired on as a new grad nurse on this telemetry unit. I like to think that what I did in my last quarter of nursing school helped me to get this new grad job. Of course there is balance with this. You don't want to look like a kiss up or overly anxious. Then you will just look creepy or like a goody two shoes. (I'm joking.) All kidding aside, you want the staff to know that you are dependable. Do your best and be a team player. All staff on the floor are important and have the same goal of caring for the patient: nurses, RT, PT/OT, dietary, cleaning staff, etc. During my clinical rotations, I would appreciate what they did for the patients and tried to show my appreciation. For instance if I could help get something for the nurses or CNAs, I would. Occasionally, I would thank the cleaning crew for their services and compliment them. It is much nicer working in a clean environment. If you do these types of things for the staff, when possible, they might remember you too and if you need a favor they may be more willing to help you. This is a good habit to have wherever you work, having the "I got your back" attitude. In conclusion, I want to remind you that when you are going through your clinical rotations, you are being watched: by staff, by patients, by your instructor. Perform with this in mind. Make a good first impression. You only have one chance to make a first impression. Remember, you are on stage. Shine on. Making the most of Clinicals Part 1: Turn negative experiences into positive learning Making the most of Clinicals Part 3: Building a good rapport with patients
  2. One of my favorite job responsibilities as a nursing instructor is nursing clinicals. It is an inspiring moment when a student is able to make the connection between classroom and hands-on nursing practice. As much as I enjoy clinicals, there are situations when student actions or behaviors can bring additional challenges to clinicals. I’ll share a few of these and, hopefully, provide you with a little helpful insight. STEP 1 Appreciate Your Instructor’s Responsibilities Your clinical instructor is legally obligated to safeguard student and patient safety. In addition, they can be held accountable for the negligent or wrongful actions of a nursing student. You can help your instructor make appropriate patient assignments by communicating your strengths, weaknesses and skill level. I have always appreciated students who perform ongoing formal and informal self-assessments on knowledge and skill. STEP 2 First Impression Really Is Important You have several "first impressions" to make on any clinical day- your instructor, patients, caregivers, clinical site staff and others. The dress code is what it is. There are certain uniform requirements as a nursing student you probably find overly strict, out-of-date or too restrictive for your own personal style. When I started nursing school 25 years ago, we were required to wear nursing aprons. It was an archaic uniform requirement, but it was also just that… a requirement. Updating your program’s dress code policy is may be a worthwhile project, but always follow current policy. Students are anxious as it is and a uniform reprimand at the day’s start only makes it worse. Be on time and eat before you come. First, I would like to acknowledge there are legitimate reasons you may be late to clinical (I.e. sick child, traffic, car problem). In these situations, be sure to follow your program’s instructions for notifying your instructor. Otherwise, leave early and allow time for the unexpected. Be sure you eat before you arrive. Asking if you can “go eat breakfast” 1 hour into clinical will probably not be well received. STEP 3 Value Your Program’s Relationship with the Clinical Site Identifying willing clinical sites for students is challenging and requires active relationship building. You can help your clinical instructor foster this relationship by: Caring for all patients with dignity and respect. Following the clinical facility’s policy and procedures (I.e. parking, non-smoking campus, patient confidentiality) Reporting any issues with staff to your clinical instructor immediately. Being realistic with facility staff expectations. Remember, the nurses are busy and stress levels may be elevated at times. Always receiving report and giving report to your assigned patient’s primary nurse. Avoiding “hanging out” at the nurse’s desk. Talk with your instructor if you are not sure what you should be doing. STEP 4 Avoid These Cringe-Worthy Faux Pas I value students who participate and focus on the present clinical. The following student behaviors take focus away from clinical, place your instructor in an awkward spot and should be avoided. Asking if group can be dismissed early because “no one will tell”. Asking questions about past or upcoming exams. Talking negatively or gossiping about other students. Talking negatively or gossiping about other faculty. Asking if post conference could be “skipped” for the day. Talking negatively about the overall nursing program. Talking negatively about the clinical site and/or staff. Arguing or disrespectful behavior toward facility staff. Studying or working on outside assignments during clinical. Asking if the student has to perform patient personal care. Complaining about “working all night” or not sleeping prior to clinical. Providing inappropriate information about personal life. Actions that risk student and/or patient safety. Finally, always avoid behavior or attitudes that diminishes, devalues or is uncaring towards any patient. STEP 5 Set Realistic Goals Pat Yourself on the Back I understand students are anxious and apprehensive. It raises a red flag when a student is overly confident and without any hesitation. Your clinical instructor appreciates a student who asks questions and seeks clarification. At the end of each clinical day, pat yourself on the back and reflect on what fear you overcame, what you learned and how you made a difference in your patient’s care. Do you have tips or stories to share? Would love to read your perspective. Additional Information: Seven Tips For Getting The Most Out of Nursing Clinicals
  3. Phoenix94

    Clinicals Advice

    Hello everyone! I'm starting clinicals in about 2 weeks. I have a general understanding of how clinicals work but how can I can use my time more wisely? I want to know what are the best things to do to get the most out the experience. Thank you in advance.
  4. olaswaisi

    No hands on skill labs?

    I need to say this because my mind is going to explode from stress. I got accepted in ABSN program in Texas with a high NCLEX rate, 97%-100%, each year, and a good reputation. I moved there and started. There are two things driving me crazy and I wonder if you guys are experiencing the same. 1-the first thing is the skills lab. What we are doing is watching videos each week, have a lecture then take a quiz on them and that is it! No on-hands training! What makes things worse is that we supposed to have a check-off on medication administration, wound care, Foley's catheter, and no lab! We are supposed to watch videos about them, go to the lab for one hour to practice those skills alone with no help, then do the check-off in front of the professors! 2-the clinicals are worse. They were telling us that clinicals will be the first semester. Fine! What is happening is we see the pts for an hour looking at their files, then the rest of the time we are discussing random subjects with the clinical professors! No, we don't practice the skills at the clinicals. Are you guys experiencing the same? How is your skill lab and clinicals look like? I know that COVID makes things more complicated, but I want to know how others do. I'm really afraid of going through nursing without proper skills. I don't think this is a good way to prepare a nurse. And I can't imagine I paid all of this money in such education. I'm thinking seriously to transfer from this school.
  5. allnurses

    Nursing Cartoons: Students

    Version August 2020

    Day to day life as a student nurse can be overwhelming and stressful. Humor is a great way to deal with stress. Throughout the years, allnurses has featured some of the best nursing cartoons focused on Students lives, along with the creative ways nursing students have found to get through some difficult days and some difficult situations. Every practicing nurse and nursing student will appreciate how these cartoons have captured (perhaps exaggerated LOL) these experiences. While in nursing school, keep these cartoons handy to put a smile on your face when you need it the most. Don't forget to share this with your favorite student nurse to help lighten their stressful days. Share your favorite toon below! About Cartoonist Jerry King: Award-winning cartoonist Jerry King is one of the most published and prolific cartoonists in the world, selling more 300 cartoons per month. His work appears in magazines, newspapers, greeting cards, books, calendars, websites, blogs, and social media. In addition to allnurses, his client list includes Disney, American Greetings, and many others around the world. Aside from greeting cards and magazines, Jerry is the author and illustrator of seven nationally published cartoon books. He has also illustrated ten children's books, and has provided illustrations for numerous children's publications. After serving three years in the army as a medic, Jerry, 42, went on to graduate from The Ohio State University with a BA in English. He now resides in NE. Ohio with his wife, daughters, and 2 dogs. When he's not at the drawing board, Jerry is probably on a golf course losing.


  6. Hi there, senior nursing student here. The other day I had my first day of clinical in the PICU and I made a completely stupid and dangerous mistake. My poor patient was on numerous drips and have numerous IVs in her right arm. One of the IVs went bad over night shift, and another went bad soon after we completed our morning assessment. She really needed another IV and she was a very hard stick. After about 30 minutes of trying, the vascular access team finally got an IV on her. Shortly after, we get busy by the doctors rounding, linen changes, trach suctioning, etc. The nurse then asks me if I can take out the IV that had gone bad upon our morning assessment. So I go ahead and take out the IV. It was the WRONG IV. I accidentally took out the brand new IV that they had just placed! Now the two IVs were very close to each other, both on the right forearm. However I still should have which was which considering I had watched them place the IV not even an hour ago. So basically I felt absolutely terrible and incompetent for the rest of the day. And worse, I will be working with this same nurse for the next month. I feel like I could write a book titled "How to make your preceptor hate you 101." Oh and even worse, this is the unit that I would like to be hired into when I graduate in 6 months. The nurse continually told me throughout the day not to feel bad, that it wasn't that big of a deal, but I know it was. This patient was a critically ill patient. She needed that IV access. Thankfully they were able to place a midline in her later on that day, but still. It was completely my fault that they had to do that. I guess now I am asking for advice on how to mentally move past this, and on how to make it up to my preceptor. Are any hopes of becoming a PICU nurse completely ruined? Because I sure feel that way right now. I am trying to let it go and go into my next shift with a positive attitude, but I just feel like I have ruined the whole thing by this one mistake. Any comments and/or advice would be greatly appreciated.
  7. Have any nursing schools cancelled clinicals yet because of COVID-19? I hear about colleges moving classroom sessions online, but have yet to hear of clinical cancellations. Are any of your schools requiring special screening for students prior to clinicals? What about travel restrictions? Some hospitals are not allowing staff to work if they have recently traveled to high risk areas. Are such rules being applied to students, too? (I coordinate student experiences for a hospital and am trying to keep track of what's happening throughout the country in this regard.) Thanks to all those who respond.
  8. Ours are called "my school name" blue, but I recently learned they are the Landau galaxy blue. I really like the color! It's better than white, green or that really light blue.
  9. Having good social skills is crucial when working in a field like nursing where a large part of your day is caring for and communicating with people. It is important to develop positive social skills so that it will be easier to succeed with your goal of becoming a good nurse. It is my goal in this article to assist you, the nursing student, to be perceptive to the patient's needs and feelings and to treat them with dignity and respect. We will discuss ways of developing a good rapport with your patient at the beginning of your clinical day. You will be surprised at how much easier your day may be when this is done. Have you ever been to a drive through window or at a restaurant and had an employee with poor social skills "help" you? They didn't make eye contact or may have been rude. It was obvious they didn't care. In the back of your mind, you wonder if they might have spit in your food. How did this make you feel? Was this a pleasant experience? Did it make you feel welcome or want to return to the establishment to be treated poorly again? Of course not, no one wants to be treated poorly. Now put this into the perspective of a sick patient. They don't feel well and now they are being "cared for" by someone who doesn't really seem to care. In my opinion, this is not a therapeutic atmosphere for a patient. Working with people can be very interesting because we are all different. We respond differently in how we are treated and how we learn and retain information. This is where your social skill building will come into play. As you work with patients you will learn how to interact with different types of patients (this also applies to a patient's family). Some patients may fit into neat little categories: the nice patient, the grumpy, stubborn patient, the scared/fearing the unknown patient, the patient who wants to be listened to, the needy patient. Some patients are all the above. I could go on and on. I have noticed that if a patient feels that you really care and you are there to advocate for them they will be more receptive to you. When you first meet the patient, it is important to make good eye contact with them, use positive body language (they are more perceptive then you think). Make it obvious that you care and that you are there for them. If the patient is on pain medications (using a post-op patient as an example) make sure and discuss a plan for the day and discuss how you will try to control the patient's pain. Doing these things will show the patient that you care. As you work with patients you will get better at interacting with them. Remember that they are people just like you, going back to my bad service at a restaurant example. Put yourself in the patient's shoes. Do you want bad service, or good service? The answer is obvious, we want to be provided with good service. Showing a patient dignity and respect is the key. Making the most of Clinicals Part 1: Turn negative experiences into positive learning Making the most of Clinicals Part 2: You're on stage-Make a good first impression
  10. Every nurse remembers their first day of nursing clinicals. I would like to share my first day with you. We were a group of ten brand new nursing students. Dressed in all white, some had excited expressions of anticipation on their faces. Others had the "deer in the headlights" look. I was blessed to have a wise seasoned nurse as a clinical instructor and she could see that some were leery of this first day of being on a real hospital unit. Much different then our cozy little lab. She decided to pair us up, two students to one patient. We were assigned to a med-surg unit. My friend, we will call her Ann, and I were assigned to a patient who was aphasic after a stroke. Prior to her admit, she had fallen and had a full leg brace on one leg. We went to her room to meet her, do vitals, get ready for bed baths. The usual first quarter tasks one would do. We found our patient covered in her own vomit, the previous nights beef stew. It was obvious it had been there for at least an hour or two. She was cold, uncomfortable and looked upset. As we cleaned her up, she was trying to tell us something she wanted. She was aphasic so she would say "I want....." and then get stuck. We tried to have her write it, again she wrote "I want" and was stuck. We couldn't turn her easily because of the full leg brace she had on. It was a very long morning. And one that Ann and I never forgot. I learned from that expererience to always check on the patient at shift change and make sure they are ok when receiving report. I also researched communicating with aphasic patients and learned different techniques in body mechanics and how to turn a patient more easily. During nursing school clinicals, there are many challenges a nursing student will encounter. You are dealing with patients. Each patient has their health problems, they don't feel well. They each have ways they want to be communicated with, ways they learn and retain better. Some patients are more friendly and patient, others are impatient and demanding. Some patients won't even let a student in the room to perform any nursing care on them. If this occurs, you must respect the patient's wishes and ask to be assigned to another patient. There are also the challenges of dealing with or working with the family of patients. This could be a different article in itself. Then there is the challenge of working with hospital staff. Some will treat you well. They will teach you and utilize you in positive ways. Others will not be so nice and will think you are in the way and give you meaningless things to do. I knew a male nurse who would ocassionally send a new student on a wild goose chase. He would ask the student to go to the attic or the seventh floor to retrieve a certain supply. We did not have an attic or a seventh floor in our hospital. Just remember that you, as a student, are a guest on their unit. They may be having a bad day, they might be very behind or have a heavy load and don't have time to teach a student. When I was a student there was a nurse who did not seem to like students. We were in the way. I was already in my mid 30's when entering nursing school so I had developed good social skills. I would say good morning to this nurse and keep walking by. She would have a look on her face that said, "what's so good about it?" I did not take this personally. And you shouldn't either. I learned from this experience. I learned that this was how I did NOT want to be when I was a nurse. I took her negativity and turned it around. I learned from it. As a nurse, you will never stop learning. There will always be something to learn every day. Remember this. If you encounter something negative, ask yourself how can I learn from this? What could I do differently next time to make this easier? What could I have said differently to make this better? Don't knock yourself down and think you don't know anything while you are in a school. I see threads like this all the time. There is so much to learn while you are in school. You will NOT know everything when you are done. When I was in my last quarter of nursing school, our professor asked us what we were concerned with as we were completing school. I raised my hand and said "I have been here three years and I am about to go out into the real nursing world and feel like I don't know anything." Almost everyone in the class nodded their heads and concurred with my statement. The professor said that this is how we should feel, we knew just enough to be dangerous. We all got a laugh out of this. He encouraged us to keep learning and growing. In conclusion, I want to remind you all that you are entering a challenging, fulfilling field. There will be times during clinicals where you will have experiences that are tough or difficult. You might make mistakes or not know the right answer. This is why you are in school, to learn. Utilize your instructors and the nurses that are there with you. If you are not sure of something, research it or ask someone. If you make a mistake, learn from it and go on. The key is to learn from it. Make it something valuable that you can carry with you through your nursing career. You will be better nurse for it. Making the most of Clinicals Part 2: You're on stage-Make a good first impression Making the most of Clinicals Part 3: Building a good rapport with patients
  11. You've made it! You passed all of your prerequisite courses, started nursing school, and you're about to begin your very first clinical rotation. What should you bring? What should you do? What if it seems like you're doing nothing? This guide will help you answer those questions, as well as help you to get all you can out of your clinical rotations to give patients and their families the very best care possible when you enter practice and continue learning as a new graduate. In nursing school, you will participate in a number of clinical courses that have a lecture component as as well as a clinical rotation where you apply what you learn in lecture. Typically, this will include fundamentals, medical-surgical nursing I and II, psychiatric-mental health, maternity/OB, pediatrics, community health, and a preceptorship capstone. Each clinical has peculiarities specific to that area, however these steps will help you in any of them! STEP 1: Research the Clinical Area! This is something I always did in nursing school. Once I knew the specific unit that the clinical would take place on, I did some background reading on the patient population, types of diseases/disorders seen, interventions done, etc. That way, when I walked onto the unit, I had at least some idea about what I would encounter. You may not know this until after your first day, but that still gives you the opportunity to do a quick review of areas relevant to the clinical area you're in. You'll look like a rockstar if you know a little about the patient population, and that can only help when you participate in patient education. STEP 2: Come Prepared! Always come to clinical with everything you need. Generally, you should bring: Stethoscope Pens Sharpie Notepad Penlight Watch Pocket Drug Guide Lunch and/or a snack Depending on the rotation, you may bring other things, or not bring certain things from that list (you don't really need your stethoscope for psych clinical). I also have a small clipboard that has clinical information on the outside and that can keep all of my papers together in one place. Another item I liked to bring was a small clinical pocket guide relevant to the clinical area. Often, nursing textbooks have a companion pocket guide, and there are also the "Notes" brand of pocket guides. So, if I was on OB/maternity, I'd bring the OB/Maternity Notes pocket guide. That way, I could look up diseases/disorders my assigned patient had, look up how to do certain procedures and skills, etc. Remember, if you're not prepared, you won't do well. STEP 3: Focus on the Basics! As a nursing student, you don't know everything. As a new graduate RN, I still don't know everything. Seasoned nurses still don't know everything. Nursing school provides the foundation for you to continue learning and experiencing for the rest of your career. Therefore, now is the time to get comfortable with the basics. Chances are you won't be able to do certain interventions. In my first clinical rotation (fundamentals), we weren't allowed to administer medications. So what can you do when you have restrictions? Focus on the basics! To me, this is focused on two areas: patient safety and patient assessment. Patient Safety One of your main goals as a nurse will be to ensure that the patient is safe while under your care. As a student, you can participate in this endeavor. Learn to ambulate patients with IVs, foleys, wound vacuums, etc (as long as they have orders to be out of bed of course!). Learn how to use the bed and chair alarms. Learn when restraints are allowed to be used. You may not be able to administer IV medications, but learn with your nurse how to check to ensure the correct medication is running at the correct rate. Patient Assessment I'll never forget one of my professors emphasizing that assessment is probably the most important skill a nurse can learn, and that assessment can save your behind (and the behind of the patient). When in clinical, if you can't do anything else, practice your head to toe physical assessment skills. Practice getting a history from the patient. If your patient has certain devices, look at them, consider how they affect anatomy and physiology, and integrate that into your clinical picture of the patient. You're told your patient has a systolic murmur or a mechanical valve, so listen to their heart. Listen to lungs for crackles and other adventitious sounds. I was always told that you may not know what you're hearing or observing, but the most important thing to learn at the beginning is when something isn't normal. Perform a head to toe assessment on all of your patients, and always take a full set of vital signs (and while we're at it, practice taking a manual BP! Often if the BP is really low or high, you'll be asked to anyway in practice, so now is the time to ensure you know how to do it!). STEP 4: Make Connections! Think about it. You want to work in a hospital (or a clinic, or in home care, or some other clinical area). You're doing your clinical rotation in a place you think you want to work in. What should you do? Make connections! Talk with the nurses on the unit, and find out what they think about working there. Ask about the experience requirements needed. Bring your resume towards the end and leave it with the nurse manager. Many students receive job offers through the connections they made during clinical. Remember, this will only work if you follow my other tips: TIP: Come prepared. Know what you're doing. Don't stand around doing nothing. Be engaged. Believe me, the nurses and others on the unit will notice. Even if you don't get an offer, the nurses that notice how engaged you are will often bring you in to see one of their patients that has something interesting going on, and this only enhances your education. STEP 5: Don't Stand Around! This is the bane of existence of every clinical instructor. They hate to see students braced against the wall, chatting about the exam they have coming up, doing nothing. Yes, you'll probably have downtime on the unit. No, this isn't the time to just stand and do nothing. If you brought pocket guides, this is the time to review pathophysiology and nursing care related to what you're seeing. This is the time to go into the patient's chart and review their history and any notes written. This is the time you could ask other nurses if they need help with anything. Who knows, maybe they'll invite you to watch something interesting! This is also the time you could help the techs/nursing assistants. If they need help to change a patient, help out! If you're allowed to do finger sticks, volunteer to do the finger sticks if you aren't doing anything else. Answer call lights. Believe me, as a student there is plenty you can be doing to maximize the limited time you have when you think there's "nothing to do". STEP 6: Medication Administration! Ah, medication administration. This is probably something we all look forward to. Most schools have some sort of limitation on what students can do in the medication administration process, often related to hospital policies as well. For my school, we were not allowed to give IV push medications. Always remember to follow the rules with medication administration. The last thing you want to happen is you giving an IV push medication to a patient, something bad happening, and you weren't supposed to, but did because the nurse said, "just pull the curtain, I'm here, lets do it" (believe me, it happens). Always remember and follow the Rights of Medication Administration. And never blindly give medications. As a nurse, you will be a licensed health care professional that has a body of knowledge that impacts patient outcomes. You never give a medication without understanding its indication, side effects, monitoring parameters, etc. Remember to look up any relevant laboratory studies or vital signs prior to giving the medication. Even if the BP was checked 30 minutes ago, I was always encouraged to check my own BP right before administering a cardiac medication, just in case. Remember, patient safety! STEP 7: Keep a Journal! I wasn't always good with this, but I know many that enjoyed keeping a journal of their clinical experiences. I used to work with a nurse that kept a journal as an RN, and would write down interesting experiences she had. I think journaling is a good idea, as you're able to write down what you saw for the day, and reflect on what you learned from those patient experiences. Journaling can help you organize your thoughts and grow as a practitioner. STEP 8: Critical Thinking is Key! This is one of my favorite things about nursing. As we know, nurses are not robots who blindly follow orders. We go through our education to learn how to assess a patient, determine problems and potential problems, make a plan of care, implement it, then evaluate the response of the patient to that plan. Wait a minute, that sounds like the Nursing Process! The nursing process is foundational to critical thinking. In your clinical rotations, read the patient's chart. Read the history and physical. Read the nursing and progress notes. Look at the lab values. Look at the radiology reports. Think about the head to toe assessment you did. Think about the medications you administered. By doing this, you see how the patient's disease relates to how they present, as well as how it relates to the problems you identify, as well as the medications prescribed. You will begin to anticipate potential problems, and ultimately learn how to advocate for patient needs. STEP 9: Care Plans are Annoying, but Helpful-Here's Why! This is related to critical thinking. We all dreaded doing care plans in nursing school. They were long, we had to use the nursing diagnosis book, and just weren't that fun. But looking back, I see how useful they are for nursing students and beginning practitioners. The care plan is how you implement your critical thinking skills and ensure that all of your patient's needs are being addressed. The care plan is the nursing process in action. So, while you may not like doing care plans, think about how much you learn about how to plan care for a patient, anticipate their needs, and how their clinical presentation affects the care you give as a nurse. STEP 10: The Preceptorship-It All Comes Together! Many schools will have a preceptorship capstone clinical in the final semester. This is where you are assigned 1 to 1 with a nurse and follow their work schedule for a set number of hours. This was hands down my favorite clinical rotation. I was assigned to a cardiac telemetry unit at a cardiac specialty hospital. I came in at 6:45am, listened to the morning huddle, got report with my nurse, and participated in everything that she did, until 12 hours later we gave report to the night nurse. The preceptorship is where everything comes together. Take advantage of this experience if you have it. You're now able to see what it's like to be a nurse for entire shifts instead of the limited time you had in other clinical rotations (often only 6-8 hours at a time). You are 1 to 1, so you see everything: the charting (I didn't realize how much was involved in charting a shift assessment until my preceptorship!), calling providers, preparing patients for surgery, receiving patients from procedures, admissions, discharges, etc. Now is your time to really be involved and learn as much as you can in this final experience. This is absolutely not the time to stand around doing nothing. Now is also your final time to make a really good impression and maybe even get a job offer at the end! I hope this guide helps you! Clinical rotations are where you see what you've been reading about in your textbooks and learning in lecture. You perform the skills and interventions you practiced in the lab on real patients. You see and participate in what it's like to be nurse in the clinical area you're assigned to, and this is not an experience to throw away. Make the most of this experience, and you will always take away something that impacts your clinical practice as a new graduate, whether or not you're in an area you have no interest in.
  12. Real nursing is not what happened at the ends of your fingers the last time you cared for a patient. No. Genuinely professional nursing is what went on between your ears when you planned the care, gave it, and evaluated its effects. Professional nursing is a disciplined thought process requiring diagnosis of problems preventing patients from achieving their best baseline health. And THAT'S the rub, right? You just can't quite find the right diagnosis to explain your plan of care to your instructor. You just can't find the right combination of words no matter how many times you thumb through your list of "NANDA's". The reason this happens is because students (and sometimes registered nurses) do not collect full and abundant assessment data on their patients. Sure, you probably noted the most remarkable things about your patient's conditions, the most obvious deformities or deficiencies... but did you assess your patient? If you're confused... the answer is NO. Let's describe what rich, abundant assessment looks like. First of all, it's systematic. Many nurses assess from head to toe. Others have a mental list of priority human needs that they click through as they interview and examine their patients. It doesn't matter what the system is, as long as you have one. The first step in your assessment is to just look at your patient. Are they looking back at you? Are they tracking you visually as you step into the room. Are they interacting with you? Or are they in some distress that is preventing them from engaging you? Without touching or speaking you've set the stage for thorough patient assessment. Next, you must know your patient's most recent vital signs and the trends they've shown over the last hours. Vital signs are called "vital" for a reason! Having done those two things... you're ready to begin your systematic assessment. Oxygen: Ask Yourself... Is my patient breathing comfortably? Is he breathing comfortably only in the bed? How about when he ambulates to the bathroom? Listen to your patient's lungs. What is the underlying breath sound and are there sounds that don't belong? What information about your patient's cardiopulmonary status can I find in the patient's records. When was his last chest film and how was it interpreted? What were your patient's most recent arterial blood gasses? Does he have a history of pulmonary problems or is he on any pulmonary related medication? Next, ask yourself... Is my patient's heart OK? Is it moving blood to the rest of his body and doing so with good cardiac reserve? Listen to his heart. Feel the pulses on all extremities, look at capillary refill. Everyone in the hospital has had an EKG, what was the reading on your patient's? Are there lab values that inform you about your patient's heart? Toponins? BNP? Look again at your patient. Are you seeing any edema? Where? Legs? Sacrum? Does he have jugular veigh distention as well? Now it's time to check out... Heme studies! Does the patient have enough RBC's with enough hemoglobin to carry oxygen to his tissues? What's his hematocrit and hemoglobin? If it is low, is it nutritional? (You might have to check out some additional labs on this one...) or is it blood loss anemia? If the latter, where is he bleeding? What do I need to assess to find out? So far so good... but the blood has to get to the tissues. Are the patient's arteries and veins competent and conveying blood to and from the tissues? Are your patient's feet warm? Equally so? Does he/she have any pain when walking (claudications.) Are his feet/ankles/legs discolored or do they show any signs of venous stasis? Fluid and Electrolytes Do you know what your patient's basic metabolic panel showed? If not... go get that data and think deeply about what it tells you! Is your patient drinking and voiding adequate amounts? If not... are we giving fluids by some other route? Figure out... If your patient is dry... why? Does this patient have functioning kidneys? If not, why not? And what do you know about the patient metabolically (as in that BMP mentioned above). Then determine if... there is any weird source of body fluid loss. (Vomiting? Diarrhea? Diaphoresis? Fistulas? Oh, and if he's on NG suction... how much is getting pulled off and how fast? Nutrition What's your patient's height/weight/BMI? Are they eating the right things? You don't need to do a food diary immediately... but IS you patient eating? If not, why not? Does you patient have teeth? If you have any suspicion of nutritional deficiency, track down that laboratory evidence so you can semi-quantify it. If your patient is on any special enteral diet (tube feeds) or parenteral feeding (TPN) figure out how many calories, grams of protein, carbohydrate and fats he/she is getting. Elimination: Basically this is about pee and poo Is your patient producing both without difficulty? When was his/her last bowel movement? And is he/she on stool softeners? Is your patient on any medication (and there are tons of them!) that can interfere with pee and poo? Rest/Restoration Is your patient in pain? Why and where? How much of the time? Is it chronic or acute? Make your patient describe the pain AND QUANTIFY ITS SEVERITY on a pain scale. What analgesics is the patient taking? When was the most recent dose taken and when can the next be given? Does your patient have any side-effects of related to the analgesic? (constipation, respiratory depression, dizziness, etc.) Are the drugs offering relief? Is your patient sleeping? Is he/she awake during the day and asleep at night? If no, why not? Semi-quantify how much sleep the patient is getting. Is the patient on medication to help him/her sleep? Are they using it? Does it work? Mobility Does your patient walk? Get up to a chair? How well does he/she toerate this? Does the patient use assistive devices? If he/she is not moving normally why not? If pain... see above. If neuro... see below. If your patient doesn't move from bed to chair to upright and walking very much, please look for the consequences of immobility. Swollen calves, skin breakdown, atelectasis. Other stuff that keeps your patient alive Clotting: Does the patient have any problems with either bleeding or thrombus formation? Is he/she on an anticoagulant? What are the most recent coagulation studies? What is your patient's platelet count? Immunity and Infection: What is your patient's white count? Is he/she running a fever? Does your patient have any predisposition to getting infected? (Wind: lungs. Water: UTI. Wounds.) Is the patient on any antibiotics? If so, do you know where the infection is? Neuro: Is your patient AAOx4? If not, describe the deficiency. Does the patient interact with you and follow you with his eyes and are his pupils PERRL? Does he have one side that works better than the other? Does he have equal strenght on both sides with grips and dorsi-plantar flexion? Can they hold their legs off the bed (one at a time) and does he have any dirft (Holding arms out with eyes closed, one arm drifts down.) Well... that's a good start. Will you make all these observations immediately? No. And that's OK. But it is YOUR JOB to have all of this information at the end of your 8-12 hour clinical day and before you go home. When you are unsure about how to express your patient's priority problem... when you're scratching your head and thinking in circles... it's almost always because you don't know enough about your patient. You MUST assess you patient before you can think rationally about his care.
  13. If I am up doing something with a patient you should not be studying for your test. I know nursing school is rough but I also know your clinical time is limited. This is your chance to see what we do day in and day out. If I am running around like a crazy person and you are still sitting at the station studying it makes me want to bonk you on the head with your text book. IT also makes me want to tattle on you to the instructor. Offer to help! I may say no but I may take you up on it! Please please please don't question my practice in front of the patient and their parents. Yesterday I had a student ask why I wasn't using adhesive remover to take off a 20 mo olds port dressing in front of his parents. I was well into the process when she asks this and he was screaming his head off. This is a very good question but this was a horrible time to ask it because it makes the parents think I am not doing what is in the best interest of the patient. Luckily my charge was there and was able to say (loudly, in front of mom and dad) that our adhesive remover can make the removal process be 2-3X longer without much relief in pain and at his age it's better to just quickly get the trauma over with. Ask away-just do it at the right time. You may know that this is not the place for you when you become an RN however that is an opinion that you should probably keep to yourself. I don't want to hear that you have no interest in peds because it makes me not want to teach you anything. Along the same lines I also don't want to hear that you think my job is depressing. I understand that this can be an emotionally trying area but I love my job and most days do not feel depressed at all! One more piece of advice... Compassion and pity are not the same thing. Almost every nursing student I have walks in to our oncology patients rooms and says something along the lines of "ohhh you poor thing" These kids do not think of themselves as "poor things' and we try to have an attitude of encouragement with them. We try to talk about the positive, remind them that they may be having a rough day but its not going to be like this forever, we will do our best to treat their pain, nausea, etc. and we try to help them develop coping tools. Of course I feel bad for these patients and their families, having a sick child is devastating. Parents and patients alike will look to us for how they should be acting so we want to present a positive for them to emulate. Don't see this as a mean rant against all students. I just want students to have some insight from a nurse before clinical.
  14. I was set to do a saline lock flush with my instructor. Mind you, it wasn't my first, because I had done them in the second semester without any problem. But it was the first one with THIS instructor, and she was very very strict. A total stickler! Ok, let's see. MAR...check! 3 ml flush intact, expiration date checked.....looking good! Alcohol swab...got it! My instructor and I walk in, I introduce her, 2 ID check with patient and MAR, explain the procedure, put on gloves....awesome! I am so good, and I even did it with a smile! So I put the flush at eye level to expel the air bubble from the syringe.....and nothing happens! I push the plunger a little more, watching my instructor across from me, her arms folded, a little smirk on the corner of her mouth. My heart is beating faster. Please God, help me! Why won't this stupid air bubble budge?! Then, before I know it, the saline shoots straight up into the ceiling, and spills down like rainwater onto the MAR on the patient's bedside table! Oh no! What did I just do? I left the stupid cap on, that's why I was having so much trouble! I look over at my instructor, who's mouth is opening and closing like a little fish. I'm so scared! Is she going to fail me? "I'm sorry", I spurted, as I picked the wet MAR, "I will get another flush and I will be right back". She follows me outside in the hall. I was so mortified, all I can say is the truth, "I'm so sorry Ann. I should have made sure to loosen the cap. It won't happen again". I gathered my supplies and do the saline flush successfully this time. As she left, she shakes her head at me and makes a gun with her hand, points it to her head and shoots. Gee, thanks, lady! That sure works wonders for my self-confidence! Fast forward to this semester....it's the last semester, yay! Finally, we are going to have a little more independence! My new instructor is superb, she tells us that this semester the cord will begin to loosen. Boy oh boy, finally we are being treated with a little respect, and like real nurses! "Emily, I have an IV to hang". "Good, get your stuff ready since you have done a lot of these, I won't tell you to step by step, I will just watch you", she says. All right! I've done tons of these before, this will be cake! I gather my equipment, tubing, labels, checked the chart, MAR, 5 checks, introduced myself to the patient, provide for privacy, explained the procedure, 2 ID'S checked, my instructor is chatting with the patient, everything's fine!! My new IV bag is primed and hanging, new tubing in place, labeled, set rate entered, volume to be infused entered. I did everything so beautifully! Geez, I was born to be a nurse, the board should just give me my license already! I'm WAY too good! Everything is set, and with a big smile I press the START button and wait for the IV to drip into the chamber... BUT I HEAR THE MACHINE BEEP! I recheck everything carefully. "I don't get it, Ana", I said, "the tubing is not kinked, the clamp is off, the machine is working, what could it be"? I look at my patient, as he gives me a shy, tiny smile. His eyes move quickly to his left. I follow his gaze only to see that I FORGOT TO HOOK HIM UP TO THE TUBING!! I gasp, as I hold it up. My instructor bursts out laughing. "I wanted to tell you so bad", she said, "but I wanted to see how long it would take for you to figure it out!" As a student, I've had my share of ditzy days and more than enough humble pie. I have learned so much about myself in this time and as a soon to be RN, I am so grateful for all the lessons I've learned! Humble pie, anyone?
  15. Let's face it, no one ever made millions off of being a nursing clinical instructor (CI) or entered nursing academia for the glitz or glamor. Most people become a CI because they are (a) passionate about their specialty, (b) have a strong clinical knowledge base, and © genuinely desire to teach the next generation of nurses. One of the biggest challenges for any CI is trying to balance the need to prove their "academic chops" to their full-time faculty peers while demonstrating their "clinical competency" to students and the clinical staff of practicum sites. What your colleagues think... In the hierarchy of nursing academia the adjunct CI is about as low on the totem pole as you can get (a rung just above the graduate student TA, I suppose). The fact is that for most nursing programs you are desperately needed so that the full-time faculty can teach didactic courses and conduct the research that brings colleges notoriety and supplemental funding, but that does not mean that you are always welcomed. Attitudes towards adjunct instructors from the full-time faculty depend largely on the culture of your institution and the example set by the administration. Behavior can range from condescending, passive-aggression, limited acknowledgment and indifference, or a quiet respect for the clinical skills that you bring to the students' education. There is also the belief by some full-time educators that nurses who remain as adjunct CI do not possess the same spirit of scholarly inquiry and do not have the aptitude for terminal degrees or research. This mindset is isolative to novice educators and dangerous for the morale of a department, not only does it create a divide between faculty but discourages adjunct CI from seeking terminal degrees or full-time faculty positions in the future. I consider myself lucky because the department chair of my program is a strong leader, supportive mentor, and remains open to suggestions about how to improve the clinical experience for students. With that being said, I received limited formal orientation to the role of CI from my program and sometimes I feel like I am on my own in uncharted waters when issues come up that are not addressed in the student or faculty handbooks. I have taken the initiative to meet some of the full-time faculty of my program, and they have largely been positive and professional. However, I wish there were more ways as a CI that I could become involved with projects at the college/university so that I could gain more experience in higher education. Inadequate orientation for new faculty members can result in role confusion and feeling unprepared to assume the responsibilities of being a nurse educator, but sadly this is not a rare occurrence (Jackson, 2015; Schoening, 2009). Having a substantial orientation is a great start for new educators, but we must also take it upon ourselves to attend conferences, engage in continuing education, and network with experienced educators who can serve as professional role models and mentors. Experienced CI should also remember what it was like to be a novice educator and take the initiative to offer guidance and support to new CI colleagues; their enthusiasm and fresh perspective may recharge your passion in teaching as well. What staff at the clinical site think... When you first begin taking students to a clinical site the staff may be hesitant to embrace you and your students because they are not sure what to expect. As the instructor, it is your job to monitor what your students are doing to ensure that they are positively contributing to the care of patients and not engaging in behavior that is counterproductive, unprofessional, or dangerous. What you cannot change initially is the previous experience that staff at the facility had with other faculty and students from your school or the reputation that your program holds within the facility. If the staff have only seen condescending, incompetent instructors or students that impede care rather than contribute to it, then the staff will not likely embrace you warmly. If they have only seen knowledgeable, professional instructors with students that are proactive and helpful, then they are more likely to welcome you with open arms. I have seen instructors who are arrogant and interact with the nursing staff as if direct care is beneath them, which leads to a poor learning experience for students. On the other hand, I have also seen instructors who are diplomatic, appreciative and acknowledge the contributions of staff to student learning, which leads to a richer experience for students. In my experience, nurses at clinical sites have a wide variety of views about CI. Some nurses place minimal value on the graduate education of a CI or feel that instructors only teach because they "couldn't hack" bedside nursing. Other nurses appreciate the level of education required to be a CI and may even seek out the expertise of a CI when they have students on the unit. Lastly, how instructors end the semester is just as important as how they begin the semester. It is not uncommon for an adjunct CI to be dismissed by a college/university from teaching for the following semester if a clinical site reports to the nursing program that they would not like to have a CI return to their site. One goal for every CI as a representative for their college/university is to maintain a positive and professional relationship between a nursing program and the clinical site. A small but significant gesture is that I make a point of ending the semester by bringing a gift to the nursing staff of the unit that I bring my students to which usually includes a thank you card and food/baked goods (pizza and cake are my personal favorites). I do this to show them our appreciation for all that they do but also to ensure that the nursing staff and management team remember our students fondly and will continue to welcome us back each semester. Read the 2nd part of this article at Confessions of a Clinical Instructor (Part II) References Jackson, B. A. (2015). Nursing students' and novice clinical instructors' experiences with clinical instruction and assessment. Walden Dissertations and Doctoral Studies. Retrieved from "Nursing Students' and Novice Clinical Instructors' Experiences With Cl" by Bridgett Alveta Jackson Schoening, A. M. (2009). The journey from bedside to classroom: Making the transition from nurse to nurse educator. Educational Administration: Theses, Dissertations, and Student Research. Retrieved from "The Journey from Bedside to Classroom: Making the Transition from Nur" by Anne M. Schoening
  16. middypiegirl

    Posterior View

    Also, you get the chance to see things you never, never dreamed you would have the opportunity to witness in person. Ever. In your life. That is where my story begins. I remember it ever so clearly. "Leslie" and I, 2 nincompoop students who had just lifted a male patient up with the Hoyer lift, transporting him to the shower to receive his bi-weekly bath. "Orville" was way out of it, as I remember he was nonverbal and didn't even crack an eyelid throughout the entire affair. We got Orville into the shower, and even though the details are foggy, I do remember Leslie positioning herself right between Orville's legs, and he was right at face level. I guess she thought maybe she had to spot him to make sure he did not fall out. This is where things got unbearably hilarious. At least, for me they did. I was fiddling around with the shower when I hear a very loud sound. It was a mix between a GASP and an AUGH. It was kind of high pitched towards the end. Right after the GAUGHSP, I heard a distinctive plop. And then a few more plops. And then a squirting farting sound. I am watching Leslie, and it all seems to go in slow motion. Her eyes open so wide I can't see her hairline, and her mouth is open in a silent scream sort of way. Then, she starts hopping up and down real fast. Ew. Ew. EW EW EW EW it's on my SHOE, there's POOP on my SHOE, get it off, get it off, oh gosh, oh why, oh POOP, on my shoe!!!!!!!!!!!!!! By this time, the tears are pouring, my stomach is cramping from laughing so hard that I am wheezing, and I can't stand. Leslie hops up and down, up and down, and then kind of starts running in place. I am trying to remain professional...but, well, that comes with practice I suppose, and I literally guffaw. Good thing the patient didn't seem to hear or care in the least that he just pooped on that nice nursing students shoe. In our post clinical meeting with the other students and our instructor, Leslie described that her lack of reflexes was due to the fact, that as she was standing right at eye level to Orville's behind, right in between his legs, she happened to notice his anus start stretching, and than open in front of her very eyes. She was in shock as she had never had a front-row view before. She stated " It just opened! Just like that!" This set off a round of guffawing from our whole class, and the next day our instructor oriented us to the Hoyer lift once more, as apparently Orville just MAY have been a little bit low in it. And so ends my story
  17. Just finished a few days of clinicals with major organizational problems. This is how our morning starts; 0645: we get our patient assignment(1 patient) 0645 till 0815: we are to have gotten report, read the patient's chart (admission history, past history,medications ordered and the rationale,lab and other diagnositic work),Check medication administration record for schedule of meds, pull the standard of care for the medical diagnosis and any labs, chest x-ray,etc., report to patient's nurse what your standard of care is for the day, do a complete head to toe assessment on the patient Including vitals, and familiarize yourself with each medication-the 6 medication rights. How does a student with limited clinical hands on do all this half way efficiently? To make matters worse our school has had major issues with getting their students clinical time(would you believe, I went through Peds,OB,Psych without any hand-ons bedside care....for the most part I was assigned to do computer simulations?? This is ridiculous. More than a few of us I believe have been mis-led by mis-led faculty advisors. It would be especially helpful to hear from someone who has been through the same situation and had turned it around.
  18. As the end of August is quickly approaching, I am starting to see more and more posts in the forums about the start of nursing school approaching for many in our community. I thought I would take a moment to share a few pieces of my story, a few tips, and some words of encouragement to complete the puzzle of mystery, nervousness, and excitement that often makes up nursing school. A few years ago, I began my pre-requisites as a pre-nursing student. I worked hard, studied hard, and in a matter of time it all paid off. I was accepted into my program and was officially a real nursing student. I obtained my first stethoscope, fulfilled my pre-clinical requirements, and before I knew it I was ready for my first day of school; the first day of the rest of my life. The first day of class was orientation and we had to wear our school scrubs. They were rough, uncomfortable, and stiff. But still, we all wore them with pride. One by one we all filled the lecture hall and as I looked around at everyone coming in I saw a similar look on everyone's face. You probably know it; it's the look that a deer gets when they look into your headlights as you're coming down the road toward them. Yeah, that's the one. We were all scared, nervous, yet so excited for the road ahead. After we were all settled in our seats our professors finally arrived, they all had smiles on their faces, a sort of calm in the storm. They began to explain the expectations of the program, told us about the clinical facilities, and even began lecturing on the fundamentals of nursing. At the end of the day we all went around the room and stated why we wanted to be nurses. Most of us said that we wanted to help people, others had a story about health issues in the family that opened their eyes to nursing, others were making a career change, and the list went on. By the end of orientation we were all exhausted and surprised by the amount of work we were in for. Later that day, we went to tour the clinical facility, it was very big and a bit intimidating for us students. We all looked around in awe at the physicians, nurses, and ancillary staff running around to tend to patients and get their work done. I looked around and I saw the nurses in their matching uniforms and on their name badges I saw those two letters that I sought after, "RN." One day, that is going to be me, I thought to myself. I watched as they swiftly moved through the hallways and envied their confidence. As time went on, we started our clinical shifts, we became more comfortable in our program, we got used to the way we were tested, and we were adapting to the workload. Each day got better, time went on, and before I knew it, our professors were talking about the different phases of being a new graduate nurse, how to register for NCLEX and obtain our licenses, and the pinning and graduation fees. Looking back on that first day, now, I can't believe how far I have come. So to you nursing students, I say, it does get better. We all started out scared. At one point or another all of us were the wide-eyed student sitting in your seat feeling worried, excited, scared, and any other emotion you might feel. Many of us have made it through and so can you. During nursing school my best friends were my fellow nursing students, we cried together, we laughed together, we studied together, I mean, I literally can't think of anything we didn't do together. Try your best to make nice with those around you. Granted, you won't get along with everyone, but do your best to learn from each other. Everyone in your program has something to offer. Make friends with the 'A' students, and if you are the 'A' student, help your peers. Also, develop strong study habits in the beginning that you can carry through to the end. During clinical, I was never at the nurse's station, unless I was charting, looking at labs, or looking at the chart. Our clinical instructors did not allow us to stand around, if you have down time, go around the rooms and check on the patients. Getting a blanket for a cold patient seems so simple, but it will likely make their day, and it gives you something to do. Stay busy. Clinical is your time to learn and soak up everything that you can before you get out in the real world. If a nurse says they are placing an NG tube, ask if you can do it! Do not be afraid to try new things. Always take opportunities when they arise and don't be a wall flower as this is your time to learn. You don't learn very much if you are sitting around collecting dust. Even if you don't get the opportunity to do something, go watch! If a fellow nursing student is putting in a catheter with your instructor, see if you might be able to watch. You get out of your clinical experiences what you put in. Even if a procedure is something only a physician can do, watch anyway! Run and tell your fellow students (as long as the patient is okay with it). Even though it may be something only the physician can do; it is still a learning opportunity. You can learn how nurses assist during those procedures. Not only that, but, there have been countless times when I went in to watch a procedure and the physician in the room taught me everything they knew. So, here I am, a few years after my first day of nursing school; a new graduate nurse. I was in your position, student nurses, not too long ago. I remember so vividly how it feels, but mark my words, it does get better. Even if you are not successful on your first try, get up, and try again. Each day will get a little bit easier, don't get me wrong, it is a lot of work, but you will learn to manage your days. Listen to your clinical instructors, listen to your body, and give it your best each and every day. You will be alright; you can make it through, and when your days get rough find that willpower from deep within. Picture yourself as a nurse when you start to feel discouraged, close your eyes, and take a deep breath. I learned quickly the importance of a good support system. Lean on your fellow nursing students and others close to you, take it one day at a time, and study hard. One day, soon enough, you too will look back on your first day of nursing school and you too will be amazed at how far you have come.
  19. So I was wondering what actually happens, and what instructors actually task you to do during clinicals? Are you just helping patients with daily living activities as if you were a CNA or are you actually doing more hardcore nursing procedures? For example, will the bulk of my clinical time be spent helping someone to the bathroom, or will I be in the OR learning OR nursing procedures or what?
  20. Julie Reyes

    The Light in Their Eyes

    I am a clinical instructor for Med Surg 1 students. I absolutely love this position. I eagerly arrived at the hospital the day before our clinicals began to meet my students for the first time and give them a tour of the hospital, as well as lay out my expectations for their semester. I think they were more eager to begin than I imagined, because even though I arrived 10 minutes early, I was the next to the last to arrive! I walked into the waiting room to a sea of royal blue uniforms. I quickly surveyed the faces and saw some anxious, some relaxed, and some...exhausted. I quickly introduced myself, and thus, began a wonderful relationship between amazing young students and me. Walking through the hospital, I pointed out where they would be doing most of their clinical time: the step down cardiovascular unit and the neuro unit. Additionally, everyone would get to spend a day in the emergency department, which they seemed particularly excited, yet nervous about. As we walked around the hospital, I could feel their anticipation and readiness to begin. We gathered in a seating area in the shade under the trees and I began to explain to them my expectations for them as a student nurse representing our university and our profession. I explained to them the grading system, when careplans were due, what I expected to see on the careplans, etc. I asked them to all take a "selfie" and text it to me with their name. Now I know they know my number and encouraged them to call me anytime they needed to discuss anything related to our clinicals - unless it was after 9pm, no one is allowed to text/call between 9pm-6am! As the first day of clinicals approached, I sent them an email outlining what group they would be in, when they were to be assigned to the ED or certain floors, and my expectations for each day. On one day, they had to show me how they assessed their patient. Another day, we went over the drugs they were administering to their patient, and why, and the education related to the medication. We discussed labs and what they meant to their patient, and if labs were not drawn that they considered important, my students learned how to effectively communicate their concerns to their preceptor or the primary care provider. My students were required to provide discharge instructions (even if the patient had days until discharge) and preventive education that would be pertinent to the patient's primary diagnosis, as well as discuss the plan of care with their patient and the family. I assisted my students as they shakily started IVs on real patients instead of a plastic arm. I watched them start or remove foleys, and provide wound care. I walked them through colostomy care and peg tube medication administration. Nervous and slowly my students began to find their confidence. I saw them hustle to take vital signs and empty foley bags, give bed baths and reposition their patient. We discussed their patient in post conference, each student giving report by following a SOAP note, and pointing out body systems in the assessment portion. We heard of the dying patient, the combative patient, the CPR and chest compressions they provided to a young man in the ED, and the crying family members left to mourn his passing. We discussed little victories, problems, questions, and concerns. We went over EKGs and murmurs so they could be able to recognize their patient's rhythm when they looked at the monitor, and recognize if that rate/rhythm was a concern. I have seen my students come in timid and insecure in their role as a Med Surg 1 Student Nurse, and I have been able to stand back and, like a proud coach (mom), watch them take off and fly. My students are now handling two patients on their own, and providing total care with confidence. They have learned how to search for answers, advocate for their patient, and stand on their own two feet. They have grown in teamwork, communication skills, and in their profession. I have seen remarkable improvements in the careplans they turn in - from the first frightful careplan that was graded pretty hard - to careplans worthy enough to be called "scholarly". I beam as I grade their papers, with goals that are realistic; interventions which are timely; pertinent rationales; and outcomes which are thoughtfully measured. As we near the last day of our clinicals, I am proud to look back on how far they have come. I review their evaluations I have been working on from the first day of clinicals until now, and I am glad that they have spread their wings and learned to fly. ....and I am grateful, so very grateful, that the future of our nursing profession is in good hands.
  21. tropanium

    Nursing Student Days

    Once, during a clinical rotation in a medical-surgical ward, a doctor asked a volunteer to check the CR (or the cardiac rate) of an unstable cardiac patient. Willing to impress my instructor because of my earlier mischief during that day (arriving 30 minutes late for our clinical rotation)...I volunteered to do that simple task. The doctor instructed me to check the CR (cardiac rate) for 1 full minute and to report back to him at once. So, full of confidence and pride at my abilities, I went to the room of the patient. Unfortunately, during that time I dont know what CR meant in the nursing profession. But I know one thing, in the Philippines there is an another meaning for the C.R. abbreviation: Comfort Room. Now, instead of checking the cardiac rate of the patient, I went directly to the patient's comfort room and assessed his toilet bowl for 1 minute to see if it is functioning properly. After 1 minute of "proper assessment", I went back with a sense of accomplishment of achieving something out of nothing and I am imagining at that time that my clinical instructor will be proud of me and my past mistakes to her will be forgotten. After arriving at the nurses station, the doctor asked me "Is my patient's CR (cardiac rate) okay?". I replied her on a matter-of-fact: "Doctor the patient's CR (comfort room) is A-okay, the toilet is flushing and you could use it if you want too." After saying that I noticed that the doctor, my group mates and most of the nursing staff are laughing at me and my clinical instructor's face is flushing with shame and anger. My Clinical Instructor pull me at one side of the room and told me that the doctor instructed to check the CR (Cardiac Rate) of the patient not his CR (Comfort Room). So because of that incident, I spent 4 hours of payment duty at that ward during that day as my payment for my mischief and I was known in our graduating class as "Mr.C.R." On our exams, regarding common Nursing Abbreviations ( e.g... ac= ante cebum? before meals), we were asked the meaning CBR s BP ( Complete Bed Rest without Bathroom Privileges). not knowing the meaning what BP stand for... I answered: CBR s BP= Complete Bed Rest without Blood Pressure....
  22. My scrubs are royal blue. As I walk into the uniform store, I cannot wait to try on the coveted scrubs! The sales lady walks over to me and asks me if I need help. I am bursting with pride as I tell her I need scrubs for my nursing clinicals. She smiles at me and leads me to the rack. Unfortunately, I am tall, and they have to order my pants. I wanted to cry! I go ahead and pay for them and buy the top so that i can sew on the nursing school patch. I am utterly disappointed that I cannot try on my ensemble and look in the mirror. Waiting flat out sucks, but as it turns out, I didn't need things to move along faster anyway. Since I am an eline student, I have to set up my clinicals by myself. I am required to contact the hospital clinical educator and do all the groundwork for setting up the clinicals at a hospital. I request one of their satellite hospitals nearer to me (30 miles) than the one in the big city an hour away. I did not realize I had to start this at least 8 weeks ahead of time! The school has never used the satellite hospital for nursing students, so there are a lot of formalities to be completed. And because everything was not done by the time clinicals were to start, I had to delay my clinicals for a semester. This was infuriating because it also delayed my graduation by 1 semester! I also don't have the benefit of having other nursing students there or a clinical instructor on campus to monitor me or help me with my questions or concerns, which is the downside of eline. I realize quickly, I am swimming in deep water on my own. I show up to the unit where I will do my very first set of clinicals about 35 minutes early. I am surprised that the day shift has yet to show up. So I wait. And wait. The day shift rolled in about 2 minutes until 7 am! Is this how they do things here? I used my time to review the patient charts, but as of yet, I have no idea what patients I will get. The nurses all come to the nurses station and I finally meet the lady who will be my preceptor. She is about a hundred and fifty years old and scowls at me when I am introduced to her. Right off the bat, she said, "I have five patients, you take This One and don't bother me." With a "deer in the headlights" look, I take her report info. "This One" is a 50 year old, 400+ pound patient who was involved in an auto-ped collision fracturing her pelvis, femur, and arm, and has a colostomy. She is in traction, in constant pain, and incontinent (well, I don't know how I could get her on a bedpan!), and I am on my own. I have never actually seen a 'real' colostomy before, and only through the textbook do I know much about changing or cleaning it out. I actually ask my patient how she takes care of the colostomy, and she is gracious enough to walk me through the process. The worst part of this experience is learning how to reposition her and change the diaper she wears since she has the fractures and is in traction. I learned (the hard way) to premedicate her prior to any of these interventions. I develop a great relationship with this amazing patient. I am so tempted to give her my telephone number and become lifelong friends with her. My heart really goes out to her because her kids don't live in the area and they are only able to come in on some of the weekends. She does have a lot of church friends who travel to see her, though. Today The Joint Commission is here for inspection. One of the officers (a retired general) stopped me to ask me some questions about what I am doing in my clinicals there. I tell him and explain exactly what patients I have and my responsibilities for the patients. He asked me about my school, and by this time, my preceptor comes by to listen to the conversation. I tell him that I am an eline student. My preceptor snaps, "I can't believe that they allow nurses to be taking nursing classes online, they can't be learning anything and it is a disservice to the profession." I am so shocked that I have no idea how to even respond, but as it turns out, I don't have to. The retired general responded, "Can you just imagine how hard it is for someone to be doing all of their schooling online and not have the benefit of going to school for face to face learning? And yet, this student nurse must take and pass all of the same exams that the face to face students must pass, and she basically has to be more motivated and focused on the goal." I smile at him as she huffs off down the hall. "Don't worry about her; some people should have retired a long time ago," he says. I feel a little lighter, now. Who knew that a face-to-face conversation with TJC could have such heart warming effects?! One of my elderly patients is due to be taken to a nursing home for the first time in his life. He had lost his wife not long before he came to the hospital. He is a true gentleman, an old cowboy who called me "ma'am" and wears his Stetson (cowboy hat) during the day when he is up in the wheelchair. His hands showed a life of hard work. He tells me stories about his wife and grown children. I talk to him for hours every day, and I hold his hand when he cries during the stories of his wife. I wish I could have met her, she sounds like an amazing woman. He confides in me and gets tearful when he says he doesn't want to go to the nursing home, but I guess that his kids can't or won't take care of him. At the end of every day, I started going by his room to tell him goodbye, and I give him a hug. I tell him I will see him on Monday. It is Monday. I am happy to be at clinicals and get back to my favorite patients. I get my assignment and notice I am missing a name on my assignment list. I ask the charge nurse about Mr. Cowboy, and if I can be his nurse again today. She looks at me and tells me he passed away Friday night. I stare blankly at her, not quite comprehending, and my heart sinks. He died in his sleep, she said. This is the first patient I have had that has died. I am not even sure how to respond, because I have to go and do morning assessments on my other patients. ...and I realize, this is the life of a nurse. You touch the lives you can, you try to help them get better, you make their time here on earth as comfortable and peaceful as possible. You do the best you can with the skills you have. Sometimes you win, sometimes you lose. I take in a deep breath and wipe my tears. And smile as I go into the next room. My journey begins!For the rest if the story, see Go to Nursing School? NEVER!! Ch 1 Culture Shock & Big Girl Panties - Ch 2 Pretzels, Puppies, and Physical Assessment Ch 3 Tales from the Crypt....uh.... I mean Clinicals. Ch 4 Give me a BREAK!!!! Ch 5 RN: Judge and Jury Ch 6 Virtual Reality Ch 7 Avoid Kids at ALL Costs! Ch 8 The End of the Tunnel...Holy Cow - is that LIGHT?! Ch 9
  23. Julie Reyes

    RN: Judge and Jury - Ch 6

    As I sit in the stands at my daughter's soccer game, I am furiously trying to catch up on my chapters I should have already read in my Maternal Newborn textbook. I feel the darkness of an unwanted presence hovering over my shoulder and look up to see my ex-husband. "Studying?" "Yeah, what's up?" "How is school?" he asks as he settles in for a conversation I have no time for. "Fine." "How are your grades?" It is at this point that I can recall the countless number of times he has told me that I am not "smart enough to be anything but a teacher" (his exact words - and he is a teacher). I remember the repetition of his dire warnings that I was stupid and would fail if I went into healthcare. I can feel the heat rising in my chest like bile. "School is fine, my grades are fine." "Really? If your grades are 'so fine', then what is your GPA?" At this point I am wondering if I can use my textbook as a weapon. However, I know the next words out of my mouth are going to be daggers to him and **** him off. "4.0". Silence. And then - "I guess that's cause you are not going to a REAL school". Yeah - that's it - a major university is not a "real school". But instead I laughed the sort of laugh you give when someone says something moronic. I thought how lucky I was that I do not have to deal with that anymore. I roll my eyes and turn my back on him, I have to study, and by study, I mean ignore him so that I don't do or say anything I can get arrested for. It's funny how quick tempered I get when I am stressed out. Nursing school will do that. I am on edge constantly. As I walk down the hospital hallway towards my patient's rooms to assess my postpartum mothers, I reflect back on the nurses I had after I gave birth. Nope, I don't remember any of them except one. I wonder if it was because there were so many new and exciting things happening in my life at the time - a new baby - and scared straight!! Would these new parents ever remember their nurses? Maybe. I assess the new mommies, help one of them learn to breastfeed, and walk back to the nurses station to fill out my reports. I actually have a huge chip on my shoulder at this time - I am tired, frustrated - I do not like this rotation at all because it is NOT my cup of tea. As I sit there at the desk, just barely tolerating existence, this huge, scary looking man walks in the unit and down the hallway. "What is this world coming to?" I ask myself. I have actually written about this - you can read the story at this link (it will help you to understand the rest of this story): I wish I were blind. I am glad I am done with my postpartum days and can move on to actually seeing a delivery. Maybe I will like this - or I hope I will. My patient is a 17 year old girl who is 17 weeks pregnant and in labor. Her mother and boyfriend are in the room, and the nurse I am following for the day is the most amazing LVN (yes - at this point in history, we used the term "LVN") - this girl knows her stuff. I cannot imagine what this poor mother is going through. She is scared and in so much pain. I care for her throughout the day, but I feel like a deer in the headlights myself. After hours of contractions, the baby is delivered. There is not a team to care for the premature infant, the baby has died in utero. My preceptor and I take the infant to another room and put his handprints and footprints in a tiny card. His hands are the size of the tip of my pinky finger. He is a little boy - all of his anatomy appears correct. He is so tiny, the width of my palm is bigger than he is. We want to take him to his mother to let her hold him, but we cannot put him in a blanket - it is too big. Instead, we wrap him in a washcloth. We head back to the room and as I hold the baby in the hallway, the nurse goes in to talk to the family and ask them if they would like to see the baby. Everyone refuses to see this little boy I hold in my hand, and I am confused. That was not the answer I was expecting. The nurse returns to the hallway and leads me back to the room we were in. We will have the tech care for the remains. Since the baby is not 20 weeks gestation, there will not be a funeral. I feel like I am in a fog - I don't understand the family decision to not see the baby - or how the young mother could be in the room laughing with her boyfriend as I hold the body of her child in the palm of my hand. I become frustrated about the decisions this family has just made! What is WRONG with them??? Then I remember the incident with the huge, scary man walking down the hallway the week before. I don't know the circumstances, I don't know the lives these people live, I don't know....anything! So how is it that I have put myself up as judge and jury? I take a deep breath and let out a sigh. I am NOT a judge, and I am NOT the jury. I realize this family is coping in the best way that they know how. I look down at the baby one last time and touch his tiny face. This is not at all a great day. My decision to never work in this area of nursing is sealed, and my admiration for the nurses who do has just been kicked up about a hundred notches. I have never been so glad to have a rotation end. The lessons I have learned about not judging others has been seared into my heart. You just never know. My journey begins! For the rest if the story, see Go to Nursing School? NEVER!! Ch 1 Culture Shock & Big Girl Panties - Ch 2 Pretzels, Puppies, and Physical Assessment Ch 3 Tales from the Crypt....uh.... I mean Clinicals. Ch 4 Give me a BREAK!! Ch 5 RN: Judge and Jury Ch 6 Virtual Reality Ch 7 Avoid Kids at ALL Costs! Ch 8 The End of the Tunnel...Holy Cow - is that LIGHT?! Ch 9
  24. Welcome student NPs and prospective student NPs! Starting your journey towards advanced practice and the provider role is a stressful time (we all know, we have been there) but also is a time to really embrace your transition and have the freedom to be an active learner. This time will be the foundation your career and your practice is built on. Unfortunately, this is a stage that is often mired by anxiety related to clinical placements. I wanted to take some time and share my personal opinions on some frequently asked questions and frequently discussed topics. I would like to offer some guidance in a two-part post on this topic, this is part one of two. First off, a little about me. I am a board-certified Family Nurse Practitioner and I work in a mixture of both inpatient and clinic settings with a small independent adult internal medicine practice. I live in a state that requires a collaboration agreement but I practice almost fully independently (as fully as I am comfortable with, see below). I have been on the clinical and didactic faculty at a local NP program as well as a lecturer and clinical preceptor for a local medical school. I have been an active preceptor for most of my NP career. I am active in the local and national NP association. I am not, however, the be-all-end-all of NP advice, so take everything as the opinion of one person with some experience. 5 Questions I Frequently Hear From Students: How do I find a clinical placement? How much RN experience do I need before I start clinicals? How do I prepare for my first clinical? What is expected of me at my first clinical? Do students really fail clinical? And here are my thoughts on each, perhaps other experienced members will add theirs as well. In part one I will take the first 5 questions as I see them. I will add a second installment with the later five out of ten. How do I find a clinical placement? Hopefully you are going to a program that helps you secure quality preceptor spots, this is my personal/professional bias, but your clinical experience is critical to your success as an NP and programs that leave that up to a student are not doing their students any favors. That being said I realize it is a trend for programs to not secure clinical sites and that there are good programs that no longer offer this. Remember there are a surplus of NP students and a relative lack of preceptors, and preceptors are (most often) not paid and often take on extra work and/or lost productivity earnings to take a student while many more are prohibited from taking students by their employer. Just like finding the right job, finding the right clinical site depends on using your existing network contacts, your school's network contacts, and making a personal effort. Talk to your family, your friends, your coworkers, your classmates, your alumni/ae, and your personal providers to see if anyone can help you get a "foot in the door" with anyone. Getting that initial contact is important. Join both the AANP and your local state NP association; they often have resources to help students find preceptors, it helps you network, and the dues are often very cheap/free for students. Make a professional and succinct resume and cover letter and hand deliver it to local practice managers; focus on small practices where you can get a face to face with the manager but also understand that many offices are very busy and won't have time to sit down with you. Cast a wide net. Don't expect to have much luck posting on message boards for preceptors. Lastly, try and avoid any paid services. They are often not helpful and offer limited guarantees and return on your investment. How much RN experience do I need before I start clinicals? This is a hotly debated topic and you can do a search on this website for a myriad of opinions. Most importantly is you need to have your RN before you can start APN clinicals. From my experience, there is no universal answer to this question. There are students with no experience that perform very well and there are nurses with ages of experience that struggle. They are, for the most part, the outliers. It is true that the RN role and the NP role are very different, but there are also important aspects they both share. I normally answer this question with a question: how much experience do you think you need? Self-reflection is very important at the provider level. The first step is to evaluate yourself and understand what you need; shadows some NPs and see if you are totally lost or ready to jump in. The second step is to figure out what your school requires. The third step is to discuss with prospective preceptors what they feel is appropriate. While RN experience may not be required of everyone there is very little argument that some RN experience won't benefit just about everyone. I don't love that some student NPs are also trying to work their first RN job, learn that role, go to school, and also do NP clinicals. There is, for me, too much confusion there. How do I prepare for my first clinical? This is one of the most stressful things for students along with the "what is expected of me" question below, and they are intimately related. The first step is to do some research on the type of practice you will be joining for your semester. You can search the internet to find the most common reasons for visits to that speciality and the most common diagnoses. You can find through your school resources the guidelines for treating common diseases in that setting. The second step is to reach out to your preceptor ahead of time and convey that you have done step 1 and ask if there is anything specific that you could do to prepare. The third step is to assemble an acceptable wardrobe to wear for your clinical rotation: it's ok to find something professional but inexpensive and wear the same thing each day (often once a week) if you don't have the money to buy a whole new wardrobe. Don't show up looking unprofessional. The fourth step is make sure you can get there on time! What is expected of me at my first clinical? As state above, this is intimately related to how you prepare. You will be expected to show up on-time and as scheduled, in appropriate attire, with a basic understanding of the type of patient you are expected to see and some general idea of the type of practice. This is pretty universal. I expect my first semester students to #1 be safe and #2 to be open to learn and active in the process. I also expect them to communicate with me openly, as I consider that part of #1 (safety). I also expect my first-time students to be able to have a general idea of how to obtain a basic comprehensive history and do a basic comprehensive physical exam. That's all I ask at the start of the first semester. On the first day I expect students to just get acclimated to the environment; meet the staff, navigate the EMR, shadow me through the day on acute and chronic visits or rounds. I welcome students to be involved with me in discussion between patients and get involved in physical findings I will identify; as above be honest if they can't see/hear/feel them. From that point on my expectations are dictated by the student: I first challenged to identify normal from abnormal as this is required for safe practice. Next I have students begin to focus their history and exam and to begin to formulate crude differentials with a focus on ruling out the most dangerous possibilities. Next I have students start thinking about potential treatment plans followed by what their actions would be on the next visit if unsuccessful. That is as far as most students will get in their first rotation. It may be basic for some, a challenge for others, but if a student can focus on those things they have a good foundation to build on. Do students really fail clinical? Yes. Students fail clinical; when it happens it is (almost) always the fault of the student for breaking very clear and simple rules. For me there are only three ways you can fail your first clinical semester. The first is that you don't show up or you show up late. There are always situations that can be excused but if you are either chronically late or unreliable you have failed yourself and thus your clinical rotation. This is the worst type of failure because t shows you are not invested in your career. The second (and most important) is that you are clinically unsafe; this changes every semester with your expectations. For a first semester student being clinically unsafe (to me) is giving medical advice your are not qualified to give, not being able to identify normal from abnormal by the end of the semester, or being unable to consider crude differentials and/or doing what I call "pigeonholing" repeatedly. This is the best type of failure because it protects your career from a lawsuit. Repeat your semester and improve. The third is not being honest with me. Your job is to be a student and it is ok to make mistakes and it is your time to see and hear and feel and learn. If I ask you to look in an ear and tell me what you think and you say "I don't know what I am looking at" or "I can see" that's fine because it's honest. If you look in the ear and say "the membrane is pearly gray and the landmarks are visible" when there is a full cerumen impaction then you are both unsafe (see the second reason) and dishonest; if you can't see and don't tell me than I don't know you can't see and you will never learn normal and abnormal (see the second reason). It's rare I fail a student but it is always in that student's control and that student's best interest. I have also had a student I failed come back and be one of the best NP's I know. It's not the end of your career it's the start of it. Read the 2nd part to this article at
  25. Hey guys. I'm currently in my second semester of nursing school (trad BSN program). Yesterday was my first day of my maternal-health nursing clinicals as I was in the NICU. The clinicals started at 6:30 and because of a family situation (had to drop off my sister bc there was no one to give her a ride to school), I knew I was going to be late, so I emailed my instructor at 6:09 AM. However, her rule is she only takes calls before 6:15, which I completely forgot. So I arrived 6:55.. Bc of my anxiety, I called my mom then called the professor. We met at 7:10. Told her my situation...she said that it wasn't an emergency, how I was unprofessional, how I had only had to call, how I would lose my license if I was really working, how I should feel sorry for myself bc I need to make myself a priority, how I didn't communicate accordingly. I apologized several times & told her that I was never late last term, she told me she didn't want to hear it. So she gave me an Unmet. And if I get two, I have a risk of failing the course. I don't know what to do bc it's not like I didn't communicate & there was no way I could just leave my sis at home. One of my friends had a similar situation & was late 40 mins, however her professor just gave her a talk because it was the first day & warned her to not let it happen again. Any advice? I've been thinking about it since as maternal nursing is one of my highest nursing interests. I'm worried.