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  1. SarahLeeRN

    Clinical Day 1: Discoveries

    Bewildered, I put the first binder back on the shelf (it was big and heavy) and turned to face the other rack. Not really sure what I was looking at but attempting to look professional, I grabbed the binder with my newly acquired client's room number on the spine, clutched it to my chest, and practically ran from the nurses' station. As I fled back to the safety of the visitor's room that the freshmen nursing students had confiscated for headquarter purposes, I could imagine that poor nurse's thoughts in the back of my mind. "That freshmen nursing student, thinks that she'll be an RN someday and she doesn't even know what a chart looks like!" I could just see her shaking her head and rolling her eyes at the inconvenience of having to deal with a floor full of freshmen. I made it back to the visitor room and sank into a chair with the chart in my lap. My need to stay in my comfort zone was very quickly overcome by my clinical instructor's orders to "Find your client's medications from the chart and write them down." Then she added with a touch of sadistic delight, "Some of these clients are going to have a lot of meds. One student last year had a client with twenty medications." Staring at my instructor with disbelief coupled with shock, I tentatively opened my patient's chart. Pages and pages of information jumped in front of my eyes. Words that I had never seen before, much less understood, attacked me from the pages. I had no idea where to even begin looking for my client's medication information. Suddenly remembering that I would need more care plan information about my client than just medication info, I was struck with the bright idea of taking my client's chart into her room and sitting with her while I attempted to decipher this terrifying binder. At least I wouldn't be under the eyes of some of the more experienced freshmen or my clinical instructor. I was still delusional enough to think that my classmates were less confused than I was. If I had actually looked around I think that I would have seen the same deer -in-the-headlights-look on their faces that was so evident on my face. Quickly sucking in my breath like a diver ready to jump, I rose from my chair, slammed the binder shut, and started walking briskly to my client's room. As I left the visitor's room I suddenly felt a surge of confidence. After all, here I was, in my new uniform, young, full of ambition and I had almost four weeks of classrooms lectures and lab time behind me! My self-confidence was returning! I felt knowledgeable, smart, and self-sufficient. And then I passed the nurses' station where I had gotten my chart. My confidence quickly dwindled as I walked, no; I sneaked, past that station. No snappy uniform or college based confidence could stand in the face of plain old experience that was represented by those sitting behind that desk. I quivered. Still clutching my binder, I made it past the nurses' station and arrived safely, albeit somewhat unconfidently, at my client's door. I then gave myself my one- thousandth pep talk of the morning. "You're doing fine, everyone feels like this on their first day. Just relax." We had been taught to always knock before entering a client's room, however, upon meeting my client earlier in the day I had discovered that in my client's instance that little textbook jewel could be thrown right out the proverbial window. I would have to hit that door multiple times with a crowbar before my client would even hear it. The dear woman's hearing was not very good, and so, I concluded that all textbook information could be adapted to meet specific client needs. Looking around me, half expecting, half afraid to see my clinical instructor behind me, I discarded textbook policy and walked right in. I walked up to my client, being careful to approach her from the front so that she could see me clearly. Leaning towards her, I raised my voice ever so slightly. "Hello, Ms. So and So! My name is------ and I am a student nurse. I am going to take care of you today!" That was my very first ever clinical experience. I wrote about this experience very shortly after it happened. I have learned so much since that day; it would take me thousands and thousands of words to even begin to scratch the surface of all that I have learned since that first clinical day. First of all, I learned that I was not alone in my feelings of nervousness. I learned that I was not the only freshmen nursing student in the world to have felt so illiterate at the clinical setting. I learned that my instructors were and are not sadistic, but in fact, want to push me to my limits and challenge me with new experiences. I learned that my instructors were approachable when I was unsure of myself. I learned that my instructors didn't mind me 'adapting' textbook policy (within reason of course!) I learned that it was possible to understand a client's chart! I learned that the clinical staff can be invaluable tools for learning, and not all of them looked down on nursing students. I learned that if I didn't know anything, I should ask questions. And the most important thing I learned that day was how to apply my textbook and lecture knowledge. I learned that no matter how much I learned in school, or how much I knew when it came down to the client, it had to be personally applied to that client. Although in the school lab, I would lose points during a re-demo for forgetting to knock on a client's door, in the "real world", if my client couldn't hear me, I had to find another way of making my presence known respectfully without knocking on the door. I had to adapt my knowledge to meet a specific situation. And that little lesson turned the 'light bulb' on for me, and helped me to understand the nursing process. It helped me to understand how to critically think a situation, even in a very small way. And I almost think that I learned more in that one tiny experience, with a hard of hearing a lady in a nursing home than in four hours of lecture on critical thinking. And, small as it was, I know that I will remember what I learned on that first clinical day for the rest of my life.
  2. vineyard

    Transcultural Nursing Experience

    My instructor said, Mr. Fernando...And I said who was that again ma'am? She repeated it, Mr. Fernando. The only thing I said to my instructor was "thank you so much and remember with a crocodile smile..." The moment I looked at the patient's chart, I was thinking like the patient's case was just okay and that everything will just be very fine of him, me and the significant others... Well, well, well, when I get into my patient's room, I was so shocked at the back of my mind because there were many bottles hanging on both sides of my patient. Not only one, two or three but there were four bottles hanging beside him. I said to myself while looking at the patient, oh-oh this is gonna be a very exciting yet tiresome job. I told my American classmate to really help me because I am anticipating that there will be a lot of calculations then and there will be a bunch of things to do. And so yes! Lots and lots of things to do. One day during my shift, I didn't notice that my patient deposited a bulk of smelly feces on his diaper and her daughter told me that the patient defecated a day before my shift. It was a very disgusting smell when I entered the room. And Ummm, of course, I don't have a choice but to clean it up because he was my patient. And Because my patient was so big, my clinical instructor called up four (4 ) other student nurses to help me. There was one guy on my right side near the patient's head (left side). One American female on my left side and there were two other student nurses in front of me. When we turn the patient on his right side, the smell went out and the guy on my right side was crying. I asked him why he was crying. I thought he was thinking like he can't make it but then he said because of the smell. He said it was the most disgusting smell he ever inhales in his life. And because at that time, we were not using any disposable towels or wipes. Everybody was asking on what are we going to wipe them. Suddenly our clinical instructor said, we can use a face towel. Yes, a face towel!!!! A face towel that my American classmate who was on my left side was used to clean up the patient's anal area. Would you believe that the towel used was the same towel being used the whole time until the patient's private part was clean?!? Meaning the towel has been squeezed with water just to make it clean 'til it has been finished. I can't believe it! After which, I removed the diaper but then because the patient was very heavy my hand slipped away and was able to touch the patient's feces! Eeeewwwwww! Yes, that was the only word that everybody was able to say right after I placed my hand on it. The patient's daughter was laughing while looking at me and said am so sorry about that. And after we saw the patient's daughter laughin' everybody smiled and said it's ok because I am used to touching feces.LOL...Yeah, it was okay because I had no choice, hehe! Furthermore, my clinical instructor asked us on who will put the ointment on the patient's butt, the guy who cried turned his head away and was smiling, said in a whisper "no, not me please..." Our clinical instructor noticed and call him with a big smile and said Yes you will ... hehe! He had no choice but to get the ointment to avoid sore. If only the patient was conscious, for sure he will laugh at us and with us. Seeing our different faces with the smile but with meaning would really make him smile too. The patient's daughter and wife were smiling that time during the procedure and they said a "warm thank you" to us because they said they can't do it by themselves because they are not used of cleaning up the patient. With it, I was bearing a crocodile smile when I heard the word "thank you..." Indeed, it was of great honor and privilege to help patients even in a very small way. That experience really helped me a lot and motivates me with regards to my patience, endurance and of being a good healthcare giver. I believe it did also test me of how much I care for my patient in any setting and cases. I am a nurse now in my country (Philippines) and hopefully work in the US soon with a true heart of giving care to my patients. I believe I could sincerely serve my future patients because life is important as how God treasure and value life. I hope that this article would enlighten all healthcare givers. May this article reminds us always that we are given a very good privilege to serve, care and above all love our patients no matter what race and which country he or she from. Have a nice day to all!!
  3. Halfway through my program, nursing school has thus far, for various reasons, ranged from being disappointing to discouraging to despairing. I've been disappointed in the quality of the school and of the clinical experience. I've been discouraged about not being inspired by my experiences in the hospital (although I've really enjoyed the occasions when I was able to get to know my patients). And I've felt despair at the prospect of my experience never changing, that I would never become passionate about nursing. And then I saw my first birth. For those who have witnessed this miracle, you know that words cannot do it justice. I've tried to describe it to friends, but it's been like trying to describe God or Goddess or maybe even chocolate. One is appropriately humbled by the attempt to get one's mind around birth, the human manifestation of creation. Sure, we can come up with all sorts of polysyllabic words to help us think we understand what's going on here, but I think we're only fooling ourselves. It is not the understanding which inspires such awe in us, it is the feeling that comes with witnessing the phenomena of birth. It is this feeling that allows us to know that something amazing and incredible and beautiful has just happened. Beyond words. Beyond art. Perhaps it is our connection to the experience of birth, our most shared experience, that has kept us from really messing things up. Perhaps, conscious or unconscious, this connection is the real source of our hope. The power of birth isn't just about the new life of a child coming into the world. It's about the unbelievable strength and courage of the mother, bearing such pain as she has never known, and knowing the deepest of love. It's about a man learning what really matters. And it's about the love of friends and family, coming together to support this mother and welcome this baby. All of this is part of what has made my one weekend working in labor and delivery the only time I have been truly excited about becoming a nurse. The very first patient I was within L&D needed a cesarean section. They were clearly disappointed at this dramatic change in their birth plans, but also grateful for the technology that would be safely bringing them their baby. I worked with the Advanced Life Support (ALS) nurse, a woman passionate about her job and eager to teach me. The baby was immediately brought over to us, quickly cleaned and evaluated. The father of a child born via c-section gets to see the baby before the mother, and this dad was right there with us, speaking to his child. I was amazed that dad's voice immediately caused the child to stop crying and turn in the direction of his father. Newborns cannot see, yet this child seemed to be looking right at his father, his familiar deep voice a beacon of comfort amidst the noise and lights of the OR. Prior to starting this rotation, I had wondered if women would be comfortable having a male nursing student take part in their delivery. I remember thinking that at least I would be able to connect with the fathers. I couldn't have been more wrong. During both of the vaginal births I attended, the mothers and her family were completely welcoming and appreciative of my presence. When I left, they gave me lots of appreciation and compliments, telling me I was going to be a great nurse. But not the dads. They barely spoke to me, but I don't think it had much to do with me. They seemed to be in shock. But once that baby was in their arms, they lit up and even smiled at me. This past Sunday a few of us sat in on a class for expecting couples. All five of the couples were having their first child, full of excitement and questions. The nurse educator led the class in exercises to try out some of the possible positions for labor and we, the nursing students, were encouraged to work with the couples during the activity. I worked with two couples, and much to my surprise and delight was able to answer all of their questions. I felt completely comfortable and confident talking with them about the birth experience and left knowing that I had done my little part in supporting them. What makes all of these positive experiences even more meaningful is the fact that one weekend I had more excitement, enthusiasm. and inspiration than in the entirety of the program up until then. I am no longer discouraged about having chosen to pursue a career in nursing and am really looking forward to my upcoming weekends working in labor & delivery. I used to think that the only significant way to really "make a difference" was to save a rainforest or stop a war or reverse global warming. Who coulda known?
  4. QuietRN

    Expected Outcome - Not Met

    I spent a lot of time coming up with interventions that I felt could really help our almost-a-century-old patient. As we pass room 221, I realize that there is a different patient there. Where's our group patient? Oh no. At that moment I know exactly where she is. She had been on my mind all week, and not just because my homework revolved around her medical history. After only three weeks in this facility, I have really grown attached to the patient in room 221. Even though I don't speak or understand a word of Spanish - the primary language of the patient - I really felt like we were able to communicate. She wasn't even able to speak Spanish at this point; her sole means of communication was through moaning/yelling. Even with this barrier, I was starting to recognize certain nonverbal signs: the small raise of her eyebrows, the opening or closing of her mouth, the slight grasping gesture her hands would make. I tried learning a couple words of Spanish so that when I was doing a physical assessment, I could at least try to let her know what I was going to be doing. The few times she opened her eyes - though just a tiny slit - were so exciting! We were communicating! The third day of our clinical had me extremely worried about this patient. We went in to take her vital signs. It didn't take long to realize that she wasn't doing so well. Her respirations were around 35/min and she felt very warm. She was also coughing and choking on thick, greenish sputum. I wished I could sit there for the full 6 hours and hold her hand. I hoped her nurse would take these signs seriously and call the doctor and the patient's family. On that 4th day of clinical, it was not surprising to learn that she had passed away. I know that death is inevitable, especially at such an advanced age. And while I was disappointed that I couldn't list my expected outcome as having been met, I was really just sad that I wouldn't get to care for this patient again. I sometimes wonder if I am too sensitive to be getting into nursing. I once thought that's what this profession was all about - caring. I see health care professionals all around me who don't even seem to know the meaning of the word. Can I become an expertly skilled nurse and still be a sensitive, caring woman who is truly concerned for the patients she cares for? It is more than just completing the interventions and meeting the expected outcome, right? It should be about making a difference in that patient's life and letting your life be touched by them as well.
  5. It's 7:20 am. I stood there for a few minutes, looking down the hall at my two companion student nurses scampering around with their buddy nurses. I watched with envy at how their mentors actually talked to them. Now, let me be fair to my mentor. When I said hello to her, she didn't completely ignore me. Her response was, "What can you do?" After three seconds of no response from me (I couldn't remember what I could do), she asked, "Can you do vitals?" "Yes." "Can you do AM care?" "Yes." And then I remembered. "AM care" includes poop. ****. I mean damn. So two minutes later I'm standing there, tumbleweeds blowing through the deserted nursing station. A crow lands on my shoulder. It's just me and those three patients, waiting for the macho nurse to change their beds, wash them down (all of them), and take their vitals. I decided to start with the quadriplegic man. The room is just a few steps away. I walk. I stop. I walk. I enter his room. I leave his room. I enter his room again. I stay. My patient is a 40-year-old Latino man, probably about 250 pounds. He says hello to me as I walk in. I say hello. I tell him I'll be right back. I look out into the hall. No one. I go back in. He's just finishing his breakfast. I take his tray, another excuse to leave the room. I come back and tell him I'm going to change his sheets. I ask him if he wants me to clean him or if he would like to clean himself. He says I can clean him. I say, "I"ll be right back." I walk down the hall, pure fight or flight. I'm ****** at being left alone, scared because I don't know what to do, and I don't want to do what I think I'm supposed to do. I'm heading to the other nursing station in search of my clinical supervisor. I see her. I walk up to her and say, "I don't know what to do." Her face softens with the compassion and wisdom of the Dalai Lama. "You know what to do," she says. "Just do what I showed you in lab yesterday. Start with the clean areas and end with the dirty areas." No problemo. I'm the macho nurse. I can do this. I walk back to my patient's room. It's 7:50 am. I walk into my patient's room, still terrified of washing his large, sweaty body. He has no motor or sensory function from the neck down (limited use of his arms), so he lives with a 24/7 Foley (urinary) catheter. And he can't tell if he needs to poop or if he does poop. Guess that's my job. I walk over to him and set up my bathing supplies next to his bed. I start to wash his face. I'm not very graceful. I realize I need another towel and need to leave the room, again. I go out and this woman is standing there. She's a "lift technician," part of the Patient Mobility Team. She grabs my arm and says, "Are you the nurse for Room X?" "Well, I'm a nursing student. I don't know anything." (did I say that last part out loud?) "We need to install an air mattress in his bed," she says. "Let's go!" A major risk to bedridden patients is pressure ulcers, the super bowl of bed sores. You can learn more about them at MedlinePlus: We're sorry, we can't find the page you requested. Air mattresses are a big part of prevention efforts. I followed her into the room. The good news here is that in order to put in the air mattress we need to change the sheets. "We" being the operative word here. "I need to wash him, too." "Well, let's get at it!" says my guardian angel. I'll call her Angel. So together we strip down this large man. I daintily apply soap and start washing with a hand cloth. She grabs a full-size towel and starts washing this guy like he's going through a car wash. She's not rough or anything. She just does it. And this is not her job. So I start putting a little elbow grease into it, washing with bigger and bigger strokes, moving down his neck to his arms, his chest, and abdomen. And voila! This guy has a penis. As I'm standing there figuring out the best angle at which to approach, Angel swoops in and starts cleaning and then I start cleaning the penis and the testicles and I look up and this guy's just reading his book. His bible no less. New washcloth in hand, I start cleaning his hairy legs and work down to his feet. Nasty. Lots of sores. I start cleaning. I remember to clean between his toes. They need it. I do it. I'm getting good at this. A real natural. Then Angel tells him we're going to turn him over and clean his back. And his butt, I think to myself. But (no pun intended) it's not that bad. It's not that great either, but I do it. There wasn't too much poop, which was nice if you know what I mean. We finish up the "bath," install the air mattress and put on the new sheets. Done. Angel says goodbye. I feel like I should buy her dinner or maybe smoke a cigarette. I don't smoke, so I just say thanks. It's almost 9 am. Even though I've successfully completed AM care, I'm still incredibly shaky. This is just too real. Where are those cute little kids I worked with as a volunteer at Children's Hospital? The rest of the day gets better, ever so slowly. While my "nurse mentor" didn't say anything to me all day, my clinical supervisor was extremely supportive. I'm not sure that I would have made it without her. She helped me with my paperwork and gave me enough compliments and encouragement to want to come back the next day. Which I did. I didn't sleep well that night. I could smell my patient, the sweat, the urine, the poop. I "took on" way too much of his situation, imagined his pain and suffering, and learned not to do that. I'm sure I'll need to learn that a few more times before I really get it. The gift and the curse of compassion. Friday. Day Two. I'm driving to work with two of my fellow nursing students. One says, "Let's set some goals for today." I said, "I'm going to stop focusing on what I imagine my patient is going through and show up with an attitude of service." Which I did. My mentor says hi to me today. The next time I see her is to say goodbye. This time I walk into my patient's room and my new confidence are immediately evident as we jump right into the conversation. We had begun speaking Spanish the day before, and today he wanted to speak English while I spoke Spanish. Fun, but not easy. I cleaned him all by myself. I washed his hair. I helped the Wound Care team and later the Physical Therapists. I did my paperwork, with interest (I refused to do paperwork as a teacher). I was like the phoenix rising from the ashes. The last hour of my second day was spent helping another nursing student bath her patient, a 64-year-old woman in a vegetative state. Another student joined us, and together we figured out how to clean this brain-dead woman who was someone's mother. We washed her and talked to her a bit, occasional sounds coming from her. I volunteered to clean her butt. Which I did. I was fifteen minutes late to our end-of-day debriefing meeting because my mentor reminded me that I needed to empty the patient's urine bag. I arrive at the meeting and sit down. I'm listening to another student share about their day and realize that I feel great. No, fantastic. I'm full of energy and enthusiasm and wow. It's 3:00 pm.
  6. Seishiro

    The Student and the School Nurse

    Privately, Mrs. R described this student as a usually happy-go-lucky individual who did very well in school and was well liked by many of her peers. One morning, however, she received a phone call from one of this student's teachers explaining to Mrs. R that the student appeared to be severely intoxicated. Mrs. R described her shock and disbelief to me and awaited the student to be escorted to her office. A few minutes later the student appeared in her office arm in arm with two staff supporting a clearly drunk young adolescent. Through tear-soaked eyes, the student confessed to Mrs. R that she was indeed drunk after consuming a large quantity of whiskey which she had let others believe was apple juice. She expressed fears of what was going to happen to her now and told the nurse that her life was over. Her main concern was getting kicked out of school. Mrs. R ensured the student that since she was honest about the incident, the student would not have to worry about being expelled. Mrs. R did explain to her however that a meeting would have to take place with her and her mother involved to discuss what had occurred today. When they all sat down around the conference table, Mrs. R remembers clearly how downcast the student appeared. The student's eyes would not meet hers and she resolved herself to staring at her hands folded in front of her. After the hearing had commenced, the conversation quickly turned to the "why" of that matter. Neither Mrs. R nor anyone else in the room was prepared for what they were about to hear. "Is it because we're homeless, student?" the mother asked without hesitation or hint of a qualm in her voice. Mrs. R paused for a moment before describing to me what happened next. After everyone stopped looking at each other incredulously, Mrs. R explained, an open and therapeutic conversation commenced that allowed the student to express her feelings without fear of judgment or punishment. The student's mother explained that if she had only had $595 dollars for a security deposit on an apartment they wouldn't be in this predicament. The student explained that all of this was indeed why she had stolen the alcohol from her sister's boyfriend's house. After the conclusion of the meeting, Mrs. R took up a collection for the student and mother to assist them to get a roof over their heads. She made the necessary calls to ensure that the apartment was still available and asked the landlord to give her a few days to come up with the cash, which he obliged. The staff at the school readily gave whatever money they could to Mrs. R to help this student and her mother get the much-needed roof over their head. Not only did Mrs. R have enough money after a couple days for the security deposit, but she also was able to afford them a $100 gift card to assist them in buying groceries. Hearing this story, it was hard to believe that the happy-go-lucky, smiling student that I saw in the office who had given Mrs. R that simple but much-deserved thank-you note was the same girl Mrs. R had just described to me. Mrs. R deserves to be looked highly upon, both as a future nurse and as a human being.
  7. Our clinical instructor asked us who would like to do these two-bed baths. One was an assist, one was complete. I jumped at the chance to do the complete bed bath. I wanted this first experience to be done and over with! My partner and I got picked to do the complete bed bath. I was relieved to get it over with but also extremely nervous. I kept on telling myself, "This is not rocket science." I think I was more nervous about making sure I maintained my patient's dignity more than anything else. My partner and I gathered our supplies and went to room 523 to help clean Mr. Wang*. We arrive at his bedside and I introduce ourselves and let him know that we are here to give him a bath. He shakes his head from side to side. Then he raises his hand as if to tell us to go away. We leave the room and I found an aide. "Jen*," I said, "I don't think he wants us to give him a bath." "Oh, he doesn't speak English," she replies. Sheesh! Wouldn't that have been nice before going into his room! I then realized, he was shaking his head to tell us he couldn't understand and trying to wave hello to us! So we go to tackle this feat once again! We each take a side and start cleaning Mr. Wang. Another nurse walks in and she has a new nurse with her. She starts changing bandages and percussing his back to loosen any sputum. She shows us how she does this. While she's doing this, I start talking to the new nurse. He tells me that Mr. Wang was from Taiwan in America visiting friends. On his way to the airport, the cab driver noticed he was very ill and took him to the hospital. It was there he was diagnosed with multi-lobed pneumonia. After we were done bathing him and receiving our lesson, I ran from the room to the student nurses' meeting room. I cried so hard. I could not imagine being alone in a foreign country, unable to speak the language, and being gravely ill. I spoke with my clinical instructor about my feelings. Was a cut out for this? Here it is, day one, and I'm already crying like a baby! She reassured me that my compassion is what will make me a good nurse. I just needed to learn how to compartmentalize these feelings. (An area which I'm still working on!) Mr. Wang was in at the hospital for a good three weeks after I saw him. Each week, I would go in and say hello. His friends had made him some cards for English and Taiwanese translation so we could communicate a little now. Not only was it nice to communicate with Mr. Wang, but he was also a great learning experience. I got to see how proper oral care was done on a patient as ill as him, sunctioning, and another procedure that I am now ashamed to admit I don't remember the name of! A bronchoscopy maybe? The best part of my experience with Mr. Wang was coming into clinical and learning that he was on his way home to Taiwan. I think about him often and wonder if he made it okay. I wonder if maybe it was a good thing he got sick here instead of his homeland? I wonder if he ever remembers us. Even if he doesn't, I know I'll remember him until the day I die. He was the one who taught me that I have the compassion to be a nurse, whether he knows it or not. *Name changed.
  8. Before you begin, investigate the floor in which you will be having the clinical. It is our responsibility as nurse educators to facilitate our students' education. In other words, we partner together with our students for their learning. It is our responsibility to create the best environment possible for learning. Cultivate an amicable learning environment by meeting with the unit manager and unit educator. Chat informally with some of the nurses just to get a "feel" for the floor. Attend one of their unit meetings or change of shift report sessions, just to give them opportunity to know you better and to be comfortable with you. Discuss the clinical expectations and limitations. Find out which nursing staff would like to work with students. This little bit of "PR" work up front can earn tremendous dividends later. You may want to "shadow" on the unit for 6-8 hours; this will help you become familiar with supplies, policy and procedures, medication delivery systems, IV pumps, charting, and primary care providers. It is very helpful to bring some "goodies" at the end of the semester to leave on the floor as a gesture of appreciation. All the students in the clinical group should sign a thank-you card to leave on the unit after the semester is finished. Other Suggestions Have clear expectations, even to the point of "stating the obvious." Make a list of things students should be doing to help organize and prioritize their day. Set deadlines and remind them often. This is especially important with first semester students, who often have little prior clinical experience. Include the basics of hand hygiene, communication with staff and patients, safety, and documentation. Require students to research their patient assignments before coming onto the unit. This maximizes precious clinical time and enhances student learning, as well as the quality of their patient care. Start each semester with very basic assignments. Have objectives for the day and stick to them. Start simple and evolve to more complex assignments as the rotation progresses. At the same time, set the bar high for expectations. People tend to rise to the level of whatever is expected of them. Be consistent and objective, and follow the facility's and school of nursing's protocols and guidelines. Consult with the charge nurse or staff as to suitable patient assignments for the students. Make sure the total assignment load is realistic (and not overwhelming or unsafe) for the clinical instructor to manage. It helps immensely to assign a "student charge nurse" or "team leader" role to rotating students each week. This "student charge" will be your right hand person, strategic in keeping the other students on track during the clinical day. This arrangement works well, even with first semester students. Communication Cultivate open communication. If you encounter a problem with staff on the floor, don't just ignore the problem, but address it at the point of conflict in a professional manner. Go up the chain of command if necessary, until the situation is satisfactorily resolved. Work diligently to maintain positive communication with the nursing staff and the unit manager. That good rapport on a unit is worth its weight in gold, but sometimes takes a lot of work. Always treat your students with dignity and respect. Strive to be fair and consistent. Intimidation makes for poor learning. We certainly cannot be personal friends with our students or cross professional boundaries by becoming "buddies," but we should encourage them and let them know we are invested in their success. There is a right way and a wrong way to correct a student. When you must correct a student, (if at all possible) never do so in front of the patient, staff, or other students. Correct in a private area, as soon after the incident as possible. Start out with a positive statement, then gently bring correction, then end with another positive comment (the "sandwich" approach). On the other hand, issues concerning patient safety can never be compromised. These situations require immediate intervention. Also, I do not tolerate an "I do-not care" attitude, sloppiness, laziness, being late for no valid reason, lack of preparation, or treating the staff/ patients rudely. If you do encounter an unsafe, ill-mannered, or unprepared student (which, thankfully, is a rare occurrence), make sure you document the situation thoroughly and objectively on the student's clinical competency form. Conferences It is a good idea to have a "quick" pre-conference before the students go out on the floor, to go over patient assignments. You can also quiz the students as to which of the patients has the top acuity or the best way to prioritize the day. The post-conference is an invaluable time for the students to debrief, discuss patient concerns, and share insights and knowledge they have gained. You can also question them about patient diagnoses and other pertinent matters: "What does congestive heart failure mean in your own words? How has this affected your patient? Why is Impaired Gas Exchange in the nursing plan of care?" Aim to inspire enthusiasm and critical thinking in your students. Being a clinical instructor is a challenging position, but with adequate planning and preparation, will prove to be a very rewarding experience. It is thrilling to watch the students grow and develop over the semester and to witness the "light bulb" moments, when it all starts coming together.
  9. The clinical instructor should be careful to promote a learning atmosphere that respects human values, rights, and choice of spiritual and cultural beliefs. Educators should be approachable, receptive, and supportive. instructors need to be excellent communicators and clear about expected clinical outcomes. Effectively leading post-conference discussions is very important. otherwise, valuable learning time may be wasted on "chit chat" and other meaningless activities. therefore, educator guidance is essential. Students should be given the opportunity to share new experiential knowledge that they gained during their clinical day. To elicit student participation, the instructor might start the post-conference session by asking each student to "share briefly about your patient care experiences today." Instructors should ask participants to talk about their feelings and attitudes concerning their clinical day in order to access affective learning, especially if the day has been very challenging emotionally. affective experiences with strong emotional reactions take precedence, because no learning will take place until the feelings have been ventilated or resolved. Questions should be used in conjunction with specific theory being taught in class that week. For instance, if the cardiovascular system was taught, then the instructor might ask questions concerning assigned patients' blood pressure, heart failure, cardiovascular medications, and other related issues. High-level questions force learners to deal with complexity and promote thinking at more challenging cognitive levels. For instance, a student might be asked, "which of your patient care problems took priority today?" Group discussions, or interactive dialogue, are another useful learning strategy for post-conference. participants might be asked to explore such relevant items as, "one of your patient's medical diagnoses is congestive heart failure. He has crackles in his lungs. How does left-sided congestive heart failure produce pulmonary edema?" Clinical case studies can be assigned to students during the clinical rotation, one case study per clinical day. Presentations should be limited to no more than 20 minutes during the post-conference period. Items the student might discuss include the prioritized plan of care, pertinent assessment data, nursing diagnoses, interventions, and expected outcomes. Another useful learning tool is the clinical concept map. Learners might be expected to draw a concept map at the beginning of the clinical day. Changes to the concept map are expected to occur throughout the patient care period. The final product can be discussed during post-conference. Short easy-to-read nursing articles can also be assigned to students, one article presentation per post-conference period. One nursing journal that I especially like to use is nursing made incredibly easy. The institute for safe medication practices (ISMP) also furnishes free clinically-relevant materials, such as the error-prone abbreviation list and the do not crush list. With a little bit of planning, post-conferences can be productive, fun learning experiences for everyone involved. I hope these suggestions are helpful to you in your teaching practice. References Baugh, N. G., & Melliott, K. G. (1998). Clinical Concept Mapping as Preparation for Student Nurses' Clinical Experiences. Journal of Nursing Education, 37(6), 253-256. HSU, l. l. (2007). Conducting Clinical Post-Conferences in Clinical Teaching: A Qualitative Study. Journal of Clinical Nursing, 16(8), 1525-1533.
  10. MachoNurse

    The Challenges of Nursing School

    When sailing, one chooses a destination and then charts a course. If the winds or currents change, the navigator must chart a new course. You don't have to change your destination, but if you don't adapt to the changing winds and currents, you will not get there. And you just might sink. I've been staying away from the keyboard because the only thing I had to write about was how frustrated and disappointed I've been this past month. Just about everything that could have gone wrong with my pediatric rotation indeed did, and I've been committed to being angry and unhappy about this situation. It's interfered with my friendships, dating, my sleep, and most, unfortunately, my experience of pediatrics. So while a small part of me would still like to rant and rave about how this has not lived up to my expectations, I am DONE complaining about this school. Really! Another one of my sea-loving friends said to me, "It's so obvious that you're passionate about becoming a pediatric nurse, and I know you will be one. Don't let these problems, or anything, distract you from your passion. Adapt, but stay focused on why you're in school." Wiser words could not have been spoken. So here is me sharing about my passion, about why I know I will soon be a pediatric nurse. This past weekend, while on our pediatric rotation, I was standing in the hall, waiting for some real action. I heard a noise from behind me. Turning around, I saw a young girl approaching me. She was the seven-year-old sister of a patient, and we had not yet met. As she walked by, I said, "Excuse me, are you a doctor?" Frowning, she replied, "No." I said, "OK, listen. The next time someone asks you if you're a doctor, you say, 'Yes, how can I help you?'" She said, "OK." We high-fived and said goodbye. An hour later I saw her again and said, "Excuse me, are you a doctor?" She furrowed her brow, closed her eyes for a minute, and said, "Yes. How can I help you?" I asked her what I can do to not get sick. She said, "Eat healthy foods." I said, "Thanks, doc." She said, "No problem." We high-fived and said goodbye. I went to see my patient and she went off to save a life or maybe get a sticker. My patients have been amazing. They are suffering; their young lives have been forever impacted by the chronic diseases that inflict their growing bodies. My six-year-old patient has kidney disease and may need a transplant. My two teenage patients, young women with amazing resilience, have chronic diseases, one of the intestine, the other of the blood. These massive health challenges have been piled atop their adventures of adolescence. I could tell they were sad, maybe depressed. And still, they laughed with me. A five-year-old girl, my favorite patient, is three days recovered from spinal surgery when I meet her. I tell her that today she will take her first steps since the surgery. It takes one hour to get her to put both feet on the floor. Another hour and she's walking across the room to her mother. I felt so proud of her, a child I had known for a mere two hours, I could have cried, shouted, and danced. I wish I had. While only in my life for a day or two, these children have forever transformed me, and unknowingly cheered me as I traverse the path of becoming a pediatric nurse. I wish I had written about these miracles as I experienced them, but I was too wrapped up in my own anger, self-pity, and victimization. This past weekend was our last of the rotation, and I was determined to learn as much as I could. I told my nurse I would like to take three patients instead of two. She was incredibly supportive, telling me she was going to show me how to do everything my instructor had neglected to teach me. I left the nurses' station filled with confidence and enthusiasm. I stopped by each room to introduce myself to my patients and their families. The kids were just waking up, so I mostly spoke with their parents. I then returned to my first patient, a four-year-old girl, to take her vital signs and do an assessment. She was incredibly shy and withdrawn, but after a few minutes of talking and playing, she started to open up to me. Just as I was putting the blood pressure cuff on her arm, another student walked in and said, "Rob, we have to leave the hospital. Our instructor is still not here." I was in shock. I said goodbye to the family and walked to the nurses' station. The other nursing students were waiting for the elevator, and the nurses were just staring at us. For the entire rotation, our instructor had been lazy and negligent to us, and annoying to most of the nurses. Her not showing up this morning was the last straw, and our entire group now had to leave the hospital. We were told we could return for the rest of our weekend, but only with another instructor. My school did absolutely nothing to remedy the situation, so we lost yet another weekend of clinical time. Our first weekend (our of five) had been canceled because this same instructor calling in sick. Needless to say, she is history, and so is my pediatric rotation. I share this because the sadness I felt at having to leave the hospital was profound. And while I first responded to this incident (and how my school ignored it) was with anger, I now see the ironic gift in it all. Being ripped away from those children hurt so deeply because I was so incredibly happy being their (student) nurse. I've been angry at my instructors and my school because it's seemed like their incompetence and negligence were endangering my chances of becoming a pediatric nurse. That was just my fear talking, and I'm done listening. I am going to be a pediatric nurse, and no bungling school or instructor is going to get in my way. And I'm done being resentful and am focusing instead of being of service, which is where this all began. I'm keeping my eye on the prize and letting passion fill my sails. That's just how the Macho Nurse (2b) rolls.
  11. VickyRN

    The Clinical Reflection

    This self-assessment enables them to carefully explore their strengths and weaknesses. The narrative account requires thoughtful consideration of successful actions that could be applied to other situations. Additionally, students can identify actions that need improvement and consider better alternatives for the future. Critically thinking on their experiences promotes the incorporation of classroom theory within the clinical environment, linking theory and practice. It also helps develop empathy by uncovering and clarifying a variety of perspectives (the patient's, the student's, and others). This personal reflective activity cultivates insight, confidence, empowerment, and healthy independence. One of my nursing students recently wrote the following touching "story" about her clinical week: The records accurately described my assigned patient as a "pleasant patient;" he was a wonderful patient. I always feel guilty for waking up patients with a fsbs test strip in my hand. I approach the room prepared for all reactions, but my patient responded with soaking kindness. While performing my head-to-toe assessment I explained the rationale of each test and action; my patient would always smile and respond with "do what you gotta do." This elderly patient had his aortic valve replaced last month. As a result of the open heart surgery, the patient was placed on "sternal precautions." To prepare for my clinical experience, I read material on the precautions and understood the importance of following all the protocols. The patient was not to reach behind him, stretch to grab something, or use his hands to assist himself out of bed. Fortunately, the patient had adls with an occupational therapist. While watching and participating in the therapy, I gained insight into the functional aspects of having sternal precautions. During this time, the occupational therapist also explained the system that is used to classify a patient's assistance level. During occupational therapy, the patient's wife called multiple times. I noted the tone was full of distress and frustration. The wife arrived at the hospital following occupational therapy and had many questions. My patient was going to be discharged the following day and his wife was uncomfortable with the idea. I gave the couple their privacy as they discussed her concerns. Meanwhile, I got in contact with the occupational therapist and relayed the wife's questions. The therapist gave me a name and instructed me to have the wife contact the case worker. It was clear to me that the wife was underestimating my patient's functional level. I suggested that she stay for the remainder of the therapy sessions, and encouraged her to express her concerns to the therapists. One of the wife's main concerns involved the patient getting in and out of their car, and climbing the four steps into their house. The physical therapist diminished the wife's fears by having the patient get in and out of the car without assistance, and allowing the wife to see the patient climb steps in the gym. The wife left the hospital still nervous but with more reassurance than when she entered. I had a wonderful time getting to know my patient. I firmly believe that older generation's stories and experiences are of value to the younger generation. History gains a new perspective when told from a first person point of view versus a textbook. Also, many mistakes can be avoided by listening to the mistakes of others. I honored my time with my patient and inquired about his history. He was a young man from North Carolina who joined the army during world war II and saw the world. He crossed the Atlantic on the Queen Elizabeth, and of his two years in the service he spent a year and a half overseas. When the war ended, he was in Paris, France. He spoke fondly of his experiences in france, and said he would do it all again. When his wife was there I inquired about their story. The wife laughed and said he had fun before they got married; he married in his late thirties. The wife moved from Virginia with her family to inhabit the small town in North Carolina. It was there that the two met, fell in love and married. They both gave marriage advice saying "marriage is about both the good times and the bad times." while discussing their story I felt tension melt away; this was one of the "bad times." Once again this couple was being stretched and asked to care for one another on an unexpected level. I learned a lot this week. I gained knowledge about transferring patients from the physical therapists, became comfortable with sternal precautions and tested my "peace making" skills. Most of all, i was able to invest into a patient and add to a man's life story.
  12. UM Review RN

    My First Nursing Instructor

    I was in my teens when I started work in a local nursing home. This was eons before HIPAA, way before the nursing home industry was regulated. This was when nursing homes were true hellholes, where residents could be restrained for days, where dressings were changed once a week or whenever someone felt like it, where doctors made monthly rounds and refused to treat patients screaming in pain because they were too old. We didn't wear gloves. Gloves were expensive and only used for sterile procedures by the nurses. I was a nurse's aide. There was no certification course for aids back then. I was taught to change the sheets every few hours and only wash the patient if there was a messy BM or if the urine smelled like ammonia. Only when the urine had turned to ammonia, I was taught, would the skin suffer harm. I worked with one other aid on two different shifts. When I worked afternoons, we would serve dinner, wash the dishes, give a couple of showers, and put the residents to bed. I loved taking care of the little German lady. She couldn't walk. She was incontinent. But she was sweet-tempered, ate all of her dinners, suffered through the cold air after the shower each night without complaint. Once in a while, she would point to something she wanted. A glass of water. Another dish of pudding. Always with a big, gentle smile. On the night shift, there were three rounds made for the 100 residents starting at midnight. It was on one of these rounds through the four open wards that the little German lady and I had our extraordinary communication. Rounds were late that night. When we threw the covers back on the little German lady's bed, the overpowering ammonia smell literally choked me. There was no disguising my expression and I didn't try to hide my disgust. I can still hear myself trying to hold my breath as we surveyed the poor woman, soaked from her head to her feet. It's hard to explain what happened next because it was one of those moments in which time suddenly melted away and all I recall is being caught up in her gaze. Her eyes brimmed full of such hurt that it made me gasp with a realization of how my reaction had shamed her. I will never forget that look, never will forget how her eyes filled with tears - not from the odor, but from my betrayal of her dignity. That is the day that I was so mortified by the behavior that I prayed to God to lose my sense of smell, to learn how to accept my patients without judgment for the things that they could not control. That day, the day that I began to see all of my patients' humanity in the episode with the little German lady, is the day that I was given the heart of a nurse.
  13. 86toronado

    Um...I Don't Know What an EKG Is

    Case in point: when I started working in the hospital, my experiences in the medical field included several emergency room visits and one overnight stay as a kid, and sleeping in a chair at my grandmother's bedside the night before she died. I guess my personality sold me to the nurse manager when she hired me on as a part-time unit clerk because it certainly wasn't my medical expertise! So on my first day of computer training for the unit clerk job, I was sitting in a room with about 15 other students in it, I was the only one who wasn't at least an LPN. We were given a page of pretending doctor's orders to enter into the computerized ordering system for practice. Now, on a side note, these were nothing like real doctor's orders. They were neatly typed (not scrawled illegibly), and they were distinctly sorted into lab tests, radiology, dietary, etc (not: BMP, CBC am, CXR am, advance diet to full liquids, troponin q8h x3, CT of abdomen stat). So, anyway, I'm pretty computer literate, so I'm doing okay, finding the tests in the computer, ordering them and checking them off. It's been pretty easy to figure out so far, X-rays come from radiology, blood tests from the lab, and food from dietary, so I'm doing okay. Except for the EKG. I have no idea what an EKG is, or where it should be ordered from. But there are about 15 other people in the room, and no one else is asking stupid questions like "What is an EKG again?" So the instructor comes over to check on me: Her: "Looking pretty good... Oh, look you missed the EKG!" Me: "Right, okay..." Her: "Let me see you put that one in!" Me: "Right, so I would... Um... I don't know what an EKG is." Her: (stares at me dumbfounded) "Cardiology services?" Me: "Oh, right, yeah I knew that!" Fast forward 2 years. The hospital and I, we got along just great. I love the chaos, I enjoy talking to the patients, and I feel like I'm really coming into my own. After I got the unit clerk thing figured out, I moved on to working as a patient care technician. I'm doing EKG's now, drawing blood, suctioning, and lots more things that probably don't need mentioning if you want to keep your lunch down. I also have three semesters of nursing school behind me. One afternoon while working on the cardiology floor, we received a patient from the cath lab, complaining of a headache when she arrived. The resident happened to be there, so the RN asks her for an order for pain medication and heads into the room to check on her patient. I'm sitting at the desk putting together the patient's chart while the resident thinks out loud to herself. Her: "Well she's allergic to Tylenol, says she takes Excedrin at home, but I probably shouldn't give her that because of the caffeine..." Me (muttering to myself): "Yeah, plus it has Tylenol in it..." Her: "Yeah. Oh well, I guess I'll just order a whole lot of aspirin..." Me (still not looking at the resident, because I don't want her to think I'm telling her what to do): "Really? Aspirin? When she's already got all that Plavix onboard from pre-procedure, she's got integrilin hanging, and she just had a large hole bored into her femoral vein? Aspirin?" I don't know what she ordered, but it wasn't aspirin. I'm going to love being a nurse!
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