When you have students on the floor...

CuriousMe · May 6, 2010

In our program, we are not allowed to pass any meds without our instructor in the room with us. It is their job to teach us. They all have access to the pyxis to pull the appropriate meds for us. We just have to communicate with the nurse as to what meds and interventions we will be able to perform each shift. Even now in my preceptorship for my final semester I am not allowed to pass meds without my nurse preceptor. For a student to just give meds without checking with you and without their instructor even on the floor is absolutely unacceptable. What if that person were on a BP med and their BP was too low to give it, etd? On the other hand, it sounds like some things need to be addressed more with the faculty and school. This kind of thing could be very dangerous for a patient!

As I said earlier in the thread, in my program second year students are allowed to give meds independently after we've been checked off each term by our clinical instructor (with the exception of IV Push meds and narcotics). The hospital gives us each our own Pyxis and EMR accounts and we're responsible for med passes on our patients.

We are also responsible to be sure to speak with the RN's and CNA's that our patient's are assigned to and be very clear about what we are taking care of that day, in addition to what we're working on/what skills we'd like to do if it comes up with another patient. We also find out their expectations for the day. If I started caring for my patients without doing this, again, I would be sent home.

I speak with my RN frequently throughout the shift. Anything that I am not checked off to do (or just don't feel confident in doing alone) I be sure to involve my RN (or instructor). It's not like we're "going rouge!"

If I was going to give a BP med in the AM.....I would be sure to taken my vitals before then, specifically keeping an eye on the BP (and the depending on the med an apical pulse). If the numbers were to low, I would tell my RN and withhold the med. (this isn't only theoretical....I've done it quite a few times this year) I'm not a med dispensary....I'm a nursing student. I know each drug I'm supposed to give that day. I know the class, the mechanism of action, the safe dosage range, potential contraindications, and drug interactions. At this point in my program, I wasn't able to answer any of these questions at any point in time during my shift , I'd be sent home. If I was unsure at any point in time, I'd be sure to involve my RN or my instructor.

I understand that other school's have different policy's, but I find it somewhat insulting that someone thinks a 2nd year nursing student would be baffled as to what to do when a BP med is ordered but the blood pressure is very low. Just because we pass meds independently doesn't mean that A) we're idiots, or B) that I think I'm an island and won't get help when I need it. It just means that the faculty in my program feel that we're knowledgeable enough to know what we need to know.....and know when to get help.

BSN/MHA/JD · May 6, 2010

my initial response to this situation is not to be so quick to judge and not to get too excited. it may well be that a student overstepped his/her bounds but, from the information we are given, it is just as likely the op was simply unaware of a critical piece of information. lets review. the op stated that she works 7p-7a and is not used to working with students. also, she has been out of school herself for only a year. we are not told what state this occurred in, so we can only guess at what the "laws" i.e. practice act may have to say. we don't know what this school or this hospital policy is regarding the supervision or autonomy of these students. we don't know what stage of their program these students may be in, etc. from the information given, we don't even know that more than one student was even involved.

questions to be answered before we pass judgment:

1. how many students were involved?

the op says she became involved with one student who was mixing meds to go in an ng. at what point or stage did she intervene? perhaps the student did nothing wrong at all, we aren't told. with the second student, the op states she had to get the med, so this student explicitly did nothing wrong. from the information given, the third student passed all the meds in question, to three patients. if it was the duty of the op to observe the students, perhaps the op was overwhelmed with having three students.

2. is this a question regarding the practice of one student nurse or a systemic problem with the way the clinical is being conducted?

we don't have enough information to draw a conclusion. if this involves poor judgment of one student, in risk analysis, i would ask why? was there something about this program that led this student to believe what he/she was doing was acceptable? what they did may have been acceptable. again, we aren't given enough information. for example, perhaps this student is in his/her final semester and perhaps, within this jurisdiction/hospital/nursing program, it is acceptable for students to pass meds to patients when they have specifically been signed off to administer certain meds. perhaps, prior to this clinical experience (earlier that day maybe) this student sat in a pre-clinical briefing with the instructor and reviewed these patients mars. perhaps these patients had no unusual or extraordinary medications, as many respondents in this string have assumed, and the students’ knowledge of all medications had been checked off. it may be the policy of this hospital, in a written agreement with the school, that students at a certain level of training and after a certain number of closely supervised med passes, may be permitted to pass certain medications. perhaps the missing bit of information is that this op was left out of the loop. perhaps there was a "required" in-service regarding how students would be supervised and what they could/could not do. perhaps the op missed this in-service and maybe this is why other staff did not seem to think this was a big deal. from the information we have, all these things are within the realm of possibility. the student may have been totally wrong. on the other hand, the op may not have had all the information.

3. we don't know what level of supervision these students (or perhaps only one student in question) had. the op states that the instructor was not in the unit. is this really the case or are we assuming this is correct. the op is a relatively new nurse and may not yet have acquired the all-seeing eye in the back of her head that many of us have developed over the years. after all, and not meaning to be critical of the op here, she was not aware when one of only three students passed meds to three different patients, until after it was over. three students is not a lot to keep track of and to lose track of one, long enough to pass meds to three patients, would tend to implicate the op, at least as much as the student, and create an implication that the students actions were acceptable. especially if this had been the practice during other clinical periods. at least that would be the argument before the board of nursing or in court with a lawsuit by the student claiming deprivation of livelihood if action was taken that prevented him/her from completing nursing school.

4. it appears that many, especially students and new nurses, are ready to condemn this student. this is how nurses get the reputation of "eating their young." cooler heads need to prevail here. without adequate information we don't need to be jumping on the bandwagon and calling for the termination of this "students" career. i'm here to tell you, in front of the nursing board, any case against this student would almost certainly be thrown out. if this student were kicked out of school, with no more information than we have here, a good attorney would easily win damages against this school and probably against this hospital. while there does not appear to be any benefit in going after the op, from this information, if harm were suffered by a patient, the op appears to be more culpable than the student. the op, in defense, could argue that she had not been adequately trained to precept students.

5. the op is looking for constructive guidance here. we don't need to rally the towns people, grab our torches and pitchforks, and head off on a witch hunt. she has, so far, done the right thing. she has learned a lesson to be more proactive in communication with students and to make sure that both she and the students have the same expectations. ask these questions: what is required in this jurisdiction regarding student actions? students can't practice nursing without a license. that exists everywhere. so, they are working under the license of someone else. however, they can perform certain duties with greater autonomy, depending on the jurisdiction, after demonstrating an acceptable skill level. to what degree does the state, the hospital, and the school require supervision? perhaps the student was fine. on the other hand, perhaps it was necessary for the student to have the meds verified for each individual patient and the instructor/preceptor to personally keep the student under visual observation until he/she entered the correct patients room. assuming we make it past that issue, what are the students used to doing? what is she (the nurse as a preceptor) comfortable with allowing students, that she is not familiar with, to do? what is the policy of the hospital? does the hospital have a training program for nurses, before assigning them to have students? if not, perhaps this would be appropriate to start.

6. if the rules had been properly provided and this student committed an error, perhaps a "pink slip" for that days clinical would be in order. this is not, as a one-time occurrence, something you kick a student out of nursing school for or even fail them in this class, unless this was told to them in advance. this is, at best, something you provide counseling for. you don't shoot your own troops every time they make a mistake. if you do, pretty soon you have no troops left to shoot and you would have to shoot yourself.

7. final thought. to those of you who are most unforgiving, stop looking for blood. this is a student. students will make mistakes, especially if thrown into a situation where it is permitted. if there is a problem here, it appears to be with the way students are supervised. stop what-ifing. maybe this student was wrong, maybe the op was wrong, maybe the hospital policy was wrong, maybe the nursing program policy is wrong, maybe the ci was wrong, maybe the pharmacy was wrong and put the wrong meds on the mar, maybe the patient had an allergy to this non-formulary, unusual, psychotropic med that was mistakenly ordered for a toe-nail fungus and the patient died. maybe the entire world will end tomorrow. or maybe, just maybe, not. we need more facts, a lot more facts, before we jump to conclusions. the op says she reported the situation but has not heard anything back. perhaps there is a good reason for that fact.

disgirlluvsdogs · May 6, 2010

that is just so wrong, for them giving medications behind your back. If i were the nurse on duty that time I will report them and escort them out as well. They don't have the right to do that, even if they know what they're doing they should let a registered nurse check all the medications they will be giving and inform the NOD of the activities that they will be doing during the shift. That is just wrong, Because if something happens to the patients it's not them that will take the blame it is you, it is your license that will be taken.

What I do when I have Student nurses is a let them give me a list of their activities, their names with their corresponding patients and I check all the medication before they give it to the patients. Also, I review their nurse charting.

NightOwl0624 · May 6, 2010

my initial response to this situation is not to be so quick to judge and not to get too excited. it may well be that a student overstepped his/her bounds but, from the information we are given, it is just as likely the op was simply unaware of a critical piece of information. lets review. the op stated that she works 7p-7a and is not used to working with students. also, she has been out of school herself for only a year. we are not told what state this occurred in, so we can only guess at what the "laws" i.e. practice act may have to say. we don't know what this school or this hospital policy is regarding the supervision or autonomy of these students. we don't know what stage of their program these students may be in, etc. from the information given, we don't even know that more than one student was even involved.
true, except i guess i didn't make myself clear. all three students were either attempting to give meds before checking with me, or had already given them without my seeing them before. i think in my original post i said 3 patients were given meds by students without me seeing them. what i shoud have said was 2 patients were given meds with no nurse checking them off, 1 patient was almost given meds without a check off, and two patients were ok because i had to get the medication out of the pyxis and either that was the only medication given, or i saw what else the student had in her hand.
questions to be answered before we pass judgment:
1. how many students were involved?
the op says she became involved with one student who was mixing meds to go in an ng. at what point or stage did she intervene? i intervened as she was opening the packets. she looked rather startled when i asked her to stop so i could compare the meds with the mar. i am rather certain that if i had come into the room 30 seconds later, all of the meds would have been mixed together ready to plunge into the ng tube. perhaps the student did nothing wrong at all, we aren't told. with the second student, the op states she had to get the med, so this student explicitly did nothing wrong. actually, and i wasn't clear in my original post, student #2 had 2 of my patients. one patient only received one medication that i got for her from the pyxis. we keep narcotics, heparin and a few other drugs in the pyxis, the rest are in a med cart and the students all knew the code (apparently). the second patient was given all of the medication without my knowledge. there were at least 5-6 oral meds that were all found in the med cart, none of those medications were from the pyxis. from the information given, the third student passed all the meds in question, to three patients. actually, again i apologize for not being clear, student #3 also had two of my patients. i saw her pass meds to one of my patients, only because she needed something from the pyxis and i saw what she already had in her hand. the second patient was given part of the medication without my seeing it. i did see one of the meds being passed on this second patient because the student came to me and said that the medication wasn't in the patient's drawer in the med cart (but it actually was). if it was the duty of the op to observe the students, perhaps the op was overwhelmed with having three students. yes, i was absolutely, completely overwhelmed. no question there!!
so actually, all three students were either passing meds without a rn present, or just about to. they only came to me to get heparin out of the pyxis or, like i said, when one of the medications was overlooked in the patient's drawer.
2. is this a question regarding the practice of one student nurse or a systemic problem with the way the clinical is being conducted?
we don't have enough information to draw a conclusion. if this involves poor judgment of one student, in risk analysis, i would ask why? was there something about this program that led this student to believe what he/she was doing was acceptable? what they did may have been acceptable. i agree, it may have been the expectation of the students that they were able to do this. since they were all doing it, it only makes sense. again, we aren't given enough information. for example, perhaps this student is in his/her final semester and perhaps, within this jurisdiction/hospital/nursing program, it is acceptable for students to pass meds to patients when they have specifically been signed off to administer certain meds. perhaps, prior to this clinical experience (earlier that day maybe) this student sat in a pre-clinical briefing with the instructor and reviewed these patients mars. perhaps these patients had no unusual or extraordinary medications, as many respondents in this string have assumed, and the students’ knowledge of all medications had been checked off. it may be the policy of this hospital, in a written agreement with the school, that students at a certain level of training and after a certain number of closely supervised med passes, may be permitted to pass certain medications. i did have the opportunity to talk to my manager this morning, and she made it clear that this was not the expectation of the hospital. she guessed that somehow i managed to end up with 3 students, when usually 1 student is paired up with 1 nurse and they can move together from patient to patient as a team. perhaps the missing bit of information is that this op was left out of the loop. perhaps there was a "required" in-service regarding how students would be supervised and what they could/could not do. perhaps the op missed this in-service and maybe this is why other staff did not seem to think this was a big deal. from the information we have, all these things are within the realm of possibility. the student may have been totally wrong. on the other hand, the op may not have had all the information. i think it was a communication problem. however, i am not clear about how the day shift handled the situation. as i said, if one nurse was paired up with one student, they may have been more closely observed if not obviously being checked off, and when night shift arrived, they assumed that they could continue as they had been - even if no nurse was around. also, day nurses tend to be more experienced - perhaps a bit more laid back with students? also, if the students arrived at 3pm, the day nurses spent all morning with the patients becoming more familiar with them. perhaps there weren't any medications given before 7pm. it seems like i just walked into a bad situation.
3. we don't know what level of supervision these students (or perhaps only one student in question) had. the op states that the instructor was not in the unit. is this really the case or are we assuming this is correct. the op is a relatively new nurse and may not yet have acquired the all-seeing eye in the back of her head that many of us have developed over the years. after all, and not meaning to be critical of the op here, she was not aware when one of only three students passed meds to three different patients, until after it was over. ok - starting to take offense here. i saw the instructor before my shift began. she told me that she would be with other students on the next floor over. it really did not occur to me to ask her specifically if they would be passing meds without a nurse present. when i asked the students, they said i would be checking them off, so i assumed that would mean i would see what they were doing so i could actually check them off. i know, shouldn't make assumptions! anyway, as i said before, and i apoligize again for not being more clear, it was not "one of 3 students that passed meds to three different patients". they were all doing things that i couldn't keep up with.
three students is not a lot to keep track of and to lose track of one, long enough to pass meds to three patients, would tend to implicate the op, at least as much as the student, and create an implication that the students actions were acceptable.
acutally, i really disagree. three students is a lot to keep track of, and as i have said several times, they were all doing things so quickly i could not keep up. i am quite sure student #1 would have put all those meds down that ng tube without my presence. (at what point would she have come to get me?) student #2 passed one patient all of his meds without me. and i am quite sure student student #3 would have passed all the meds to one of the patients if she had found all of the drugs in his drawer. that she came to me saying it wasn't there, and it was quite there in his drawer, right out in the open, concerned me as well. i'm wondering if she was even in the right patient's drawer when she pulled out the other meds that she gave to the patient without me seeing them.
especially if this had been the practice during other clinical periods. at least that would be the argument before the board of nursing or in court with a lawsuit by the student claiming deprivation of livelihood if action was taken that prevented him/her from completing nursing school.
4. it appears that many, especially students and new nurses, are ready to condemn this student. this is how nurses get the reputation of "eating their young." cooler heads need to prevail here. without adequate information we don't need to be jumping on the bandwagon and calling for the termination of this "students" career. i'm here to tell you, in front of the nursing board, any case against this student would almost certainly be thrown out. if this student were kicked out of school, with no more information than we have here, a good attorney would easily win damages against this school and probably against this hospital. while there does not appear to be any benefit in going after the op, from this information, if harm were suffered by a patient, the op appears to be more culpable than the student. the op, in defense, could argue that she had not been adequately trained to precept students. no idea, but i can tell you quite certain that in the program i graduated from, i would have failed the class if i had passed meds without a registered nurse checking them first. don't know the policy of this school. not sure how i would be more culpable than the students, exactly. i absolutely agree i am not trained to precept students. i sure wouldn't volunteer for that position at this stage of my career! i didn't even know students would be there that day. besides, isn't it the job of the instructor to teach the students? if she is not responsible for them and i am, shouldn't i know what they are doing?
5. the op is looking for constructive guidance here. yes - and i think i have gotten some really thoughtful replies! we don't need to rally the towns people, grab our torches and pitchforks, and head off on a witch hunt. no, don't want that, either. i did not "report" the students, yell at them, embarass them or any such thing. just wondered if this was common practice and if i was out of line with my expectations. she has, so far, done the right thing. she has learned a lesson to be more proactive in communication with students and to make sure that both she and the students have the same expectations. absolutely!!! ask these questions: what is required in this jurisdiction regarding student actions? students can't practice nursing without a license. that exists everywhere. so, they are working under the license of someone else. however, they can perform certain duties with greater autonomy, depending on the jurisdiction, after demonstrating an acceptable skill level. to what degree does the state, the hospital, and the school require supervision? perhaps the student was fine. on the other hand, perhaps it was necessary for the student to have the meds verified for each individual patient and the instructor/preceptor to personally keep the student under visual observation until he/she entered the correct patients room. assuming we make it past that issue, what are the students used to doing? what is she (the nurse as a preceptor) comfortable with allowing students, that she is not familiar with, to do? what is the policy of the hospital? does the hospital have a training program for nurses, before assigning them to have students? if not, perhaps this would be appropriate to start. yes, i agree on all accounts. i have certainly learned not to assume anything!!
6. if the rules had been properly provided and this student committed an error, perhaps a "pink slip" for that days clinical would be in order. this is not, as a one-time occurrence, something you kick a student out of nursing school for or even fail them in this class, unless this was told to them in advance. this is, at best, something you provide counseling for. you don't shoot your own troops every time they make a mistake. if you do, pretty soon you have no troops left to shoot and you would have to shoot yourself. agree with that, too!
7. final thought. to those of you who are most unforgiving, stop looking for blood. this is a student. students will make mistakes, especially if thrown into a situation where it is permitted. if there is a problem here, it appears to be with the way students are supervised. stop what-ifing. maybe this student was wrong, maybe the op was wrong, maybe the hospital policy was wrong, maybe the nursing program policy is wrong, maybe the ci was wrong, maybe the pharmacy was wrong and put the wrong meds on the mar, maybe the patient had an allergy to this non-formulary, unusual, psychotropic med that was mistakenly ordered for a toe-nail fungus and the patient died. maybe the entire world will end tomorrow. or maybe, just maybe, not. we need more facts, a lot more facts, before we jump to conclusions. the op says she reported the situation but has not heard anything back. perhaps there is a good reason for that fact. i spoke to my manager today. we had a good talk, she gave me some tips on how to work with students, and said that i was completely in my rights to tell students what i am comfortable with, even if it is more restrictive than their school policy.

thank you for writing such a detailed response. while you raise some really good points, i just felt like i had to clarify some misconceptions because all three of the students were behaving the same way, not just one. i did not want my first post to be so long and detailed that no one would read it.

i really did not expect the kind of responses i received, and so many of them. other than making the mistake of assuming that checking off medication would mean that i would actually see the medication, i don't think i did anything wrong here. i may be new, but i'm not stupid. i learned a good lesson about assumptions and communication. none of the patients got hurt. the students have probably finished their semester successfully. i still have a job and my license. it's all good!

alodocios · May 6, 2010

:uhoh3:

When i was an lpn student, our instructor 1st: had to be on the same floor with the students. 2nd wasn't allowed to have more than 10 students per instructor, and they had to access the pyxis with their id, we didn't have independent access to it. They had to watch us draw up any injections, and until you got checked off on a skill, they had to be there for those too. When we got checked off for a certain amount of med passes, we could pass meds independantly but only after the instructor watched us obtain the meds. We never could get meds by ourself, we didn't have access it just wasn't allowed. we had to get vitals, tell the instructor about any special things we should be concerned about and they made sure we knew what we were doing before they sent us into a patient' s room unsupervised.

Dianacabana · May 6, 2010

In my school this would have been impossible to happen. Instructors are at the pyxis with us, reviewing every medication and at the bedside for administration. Was the student aware of the guidelines? I would have taken aside all the students for whom you were responsible and made your expectations clear. Remove them from the bedside if necessary! But I really think the instructor is supposed to be ultimately responsible for them, NOT you.

NightOwl0624 · May 6, 2010

With 3 students, all hopefully trying to get their med pass done on schedule, I really don't know how you would have been able to check all of their meds and such beforehand.
If I had been organized enough and had some insight as to how this was going to happen, it's really quite easy for a student to gather meds, bring them and the med sheet to the instructor or the nurse, check them off, and proceed to pass them. When I was in school, the instructor stood in one place, we lined up and checked off. Yes, it did take a little more time, as there were 8 students with one instructor, but I don't think that these 3 students would have wasted all that much time by taking that additional step. A minute or so perhaps? But the way it turned out, I seemed to be chasing them and that didn't work at all.
I guess in the writers' case there should have been more communication between the nurse, the instructor, and the student regarding duties and expectations. Absolutely!!! Oftentimes during my clinical shifts my nurse and/or instructor were not even available to me as needed. Again, in those moments I would never do anything that I was not previously checked off to do, but the thought of sitting idly by and doing nothing didn't seem like it was a viable option when I was there to practice my nursing skills and gain valuable knowledge and experience.
Even when I graduated and hired on to this position, I never passed ANY meds that my preceptor did not check off herself UNTIL the day I passed the NCLEX. As annoying to me as it was.... And I was done with school and working as a grad nurse!
Hopefully, this incident at least gave you a new perspective in the responsibilties of working as a preceptor/nurse instructor. It certainly did!!!

Thanks for your insight!

BSN/MHA/JD · May 7, 2010

thank you for the clarification, especially with regard to your conversation with your manager. it appears that you handled this very professionally.

it also makes it clear that this nursing program has some kinks to work out. you were apparently the victim of poor planning by having three students assigned to work with you when the norm in this program and at their stage of training, should have been 1:1. i have seen many programs and worked with students in many different settings. what should have occurred here is for the hospital to have a clear agreement with the school as to how students will be assigned to work with staff. the ci for the program should identify which students she/he would like each student to work with (to ensure students are getting the appropriate experience). ideally, this should be done the day before. this permits the instructor to make assignments and for the students to research their patients before they start the clinical assignment. (at times, last minute changes will occur when a patient is unexpectedly discharged.) for an evening rotation, the ci could make the assignments early in the morning, as long as the unit manager has a chance to review the assignments. the unit manager (or charge nurse) should then review the desired assignments selected by the ci in order to make the appropriate work assignment for the regular staff. this will ensure the students receive proper supervision. the hospital should also require staff to receive training in what to expect and what is required when working with students. this will help to ensure that all staff understand their roll, what tricks to watch out for when working with students, and what the potential legal pitfalls are. i have found the whole concept of law within a hospital environment is usually based on rumor and the most creative imaginations rather than actual fact, state statute, and case history. many hospitals require staff to attend training and be "certified" as a preceptor before they have students. this includes new hires as well as nursing students.

given the situation you have now described, i can imagine how quickly you could become overwhelmed. that soon in my career i am certain i would have been also. at this point, what i would have done is to start my shift by gathering my peeps and setting boundaries. you should keep things at your comfort level, even if the students feel they can handle more. you are not familiar with them, their knowledge, or their attention to detail. if need be, let them know they can do all the cna functions but if they are going to do a treatment, look under a dressing, start an iv, or so much as carry a medication into a room, you must be with them. the less the school has explicitly outlined and adequately trained both the hospital staff and students to expect of each other, the more explicit you must be in establishing boundaries.

your charge nurse should have been responsible for ensuring you did not get placed in this situation. it sounds like you were failed by a less than adequate hospital/school agreement, inadequate hospital preparation of staff members who are responsible for working with students, a ci and a charge nurse that permitted three students to be assigned to you, and over-eager students who wanted to show what they could do, without realizing that you are the last defense between their learning and patient safety.

please don't take offense at some of my comments. not being there, i could not see what you were actually faced with. my intent is not to be critical of you, just critical of the many comments from nurses that are all too ready to feed these students to the wolves. people make mistakes and every one of the people making comment here has made mistakes. if they say they haven't, they can't be trusted. it's just a matter of time before all of us make another mistake. the goal here should be to figure out why these students all thought they could pass meds this way. perhaps it wasn't entirely the students fault.

an even bigger issue for me is that so many nurses are leaving comments that seem to be of the opinion that making a med error justifies kicking people out of the profession. it doesn't. we need to stop equating med errors with punishment. this only means that when errors are made, nurses will try to hide the error. i am in favor of having a no penalty policy toward med errors. risk management needs to be aware of when and how errors occur so they can fix the situation that permitted the error. this is the very reason we now use a pyxis. this is why the pharmacy goes to such great effort to place each patient's meds into that patient's drawer in a med cart. the way the system used to work was that all meds were in the med room. the nurse would read the doctor's orders and then go to the med room to find the bulk container. hopefully having the right container, the nurse would then take out the appropriate amount of medication and administer it to the patient. the five rights were developed because of the problems with this system. we are now assisted with getting the right patient because the pharmacy has already placed the medication in that patient's drawer or pyxis profile. we are assisted with getting the right medication because the pharmacy has not only verified the order but also obtained the medication and placed it in that patient's drawer. we are assisted with getting the right dose because most meds now come in an individual dose packet. the nurses still have to ensure they get the right route for a medication but i have seen some pretty inventive ways of misunderstanding this right. we are also assisted with the right time by having electronic systems that remind us when medications are due. nevertheless, errors do happen. there are medications that should not be given together, treatments and procedures that must be done correctly, and proper instruction and teaching that must be done.

even improperly performed cna duties can lead to the death of patients. for example, my own father died following a survivable stroke after a cna fed him pudding, on which he aspirated. this could have been prevented by the doctor not ordering a diet for him, the kitchen not providing a tray for a stroke patient, the nurse intercepting the tray so that it could not be fed to the patient or the cna being taught the danger of feeding a stroke patient. this event was unfortunate and avoidable, however, it does not justify terminating the career of all those involved.

as far as the culpability issue, i don't want to go into too much detail here because it is a lengthy subject dealing with legal standards and the wording of nurse practice acts. you are correct that the instructor should be responsible for the students. however, since the instructor was off the unit, with your knowledge, you assumed responsibility for the students. the students are pretty much immune from anything that is done wrong. almost never will a lawsuit go after an individual nurse unless they have active with gross negligence (bordering on an intentional wrongdoing). if a patient suffers harm, an attorney will go after the hospital or even a doctor. these are the ones with deep pockets and big malpractice insurance policies. nurses seldom have personal malpractice policies. if they do, they become a lightning rod and are more likely to end up as a defendant. nurses are less likely to end up in court but more likely to end up before the nursing board, with the threat of action against their license. this is not court, it is a hearing, but it functions in a similar manner. if there had been patient harm, the students could simply say they were working under the license of a nurse, whom the nursing board has control over. the students could be held liable for criminal conduct but this is very hard to prove and must be an intentional wrongdoing. the nurse simply has to be responsible for failure to supervise. this almost never happens and the facts generally have to show extreme disregard for patient safety.

anyway, i think you did the right thing. this situation exceeded your comfort level and you raised the issue to your unit manager, the ci, and hopefully to risk management. it is these peoples job to do a root cause analysis and handle the situation professionally, to prevent a future occurrence and keep everyone safe and within the law. not to find a scapegoat so the situation can be swept under the rug, just waiting to happen again when the conditions are right.

pmshaver · May 7, 2010

You are absolutely correct to be outraged! As nursing faculty, I would find this possible grounds for failing clinical. Very unprofessional behavior. Manager should talk with faculty member and faculty member should speak with students.

NightOwl0624 · May 7, 2010

thank you for the clarification, especially with regard to your conversation with your manager. it appears that you handled this very professionally.
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anyway, i think you did the right thing. this situation exceeded your comfort level and you raised the issue to your unit manager, the ci, and hopefully to risk management. it is these peoples job to do a root cause analysis and handle the situation professionally, to prevent a future occurrence and keep everyone safe and within the law. not to find a scapegoat so the situation can be swept under the rug, just waiting to happen again when the conditions are right.

thank you for your support and detailed information. i really appreciate the time you have spent sharing your knowledge and opinions regarding this issue.

Nrscass · May 7, 2010

Wow, all I can say is that sounds frightening. I am a new grad from a fabulous school and I can tell you right now that these are circumstances for termination from the program. I would be upset, it is not only out of their scope of practice, even if they are block 4....but unsafe and the bottom line is it is your license on the line. I would pursue the follow up and address the clinical instructor, they should be able to figure out what to do with the students. I never would think about med administration without my nurse preceptors approval!!!!!!!!

Good luck, I hope all works out for you and your patients!

AmericanRN · May 7, 2010

When I was in nursing school we had a skills check off sheet. We were watched each semester by whoever the clinical instructor was, if they were comfortable with you that one time, that was the end of it as far as med passes went. With that said it was the responsibility of those students to ask you if they could do that without you observing them since they were shadowing you that day. I've had many nurses especially those in facilities who were familar with how our school trained us, allowed us to med pass alone if they saw that the skills check off list was already signed by the instructor, with the exception of drawing up insulin. There was always a 2nd check behind that.

Statement 1: The students should have asked you before passing anything but on the other hand this may be a training oversight from their school and not intentional disrespect towards you. They may have honestly thought they were helping you instead of causing mayhem and possible patient injury.

Statement 2: I see people using preceptor interchangeably with shadowing a nurse for the day. Not all nurses are preceptors and just because you are shadowing a nurse for the day doesn't make him or her the student's preceptor. I've shadowed many nurses but I only had one preceptor and I worked her whole shift with her not just a few hours like what usually happens in school. In my state Preceptorships are actual written contracts between a nursing student close to graduation and a nurse that was hand chosen by the facility's nurse educator. A clinical instructor saying "go with that nurse for today" is not a preceptorship in any capacity.

I see many people rooting to kick these students out without knowing what the whole story is behind these actions. Here's the biggest question 1) Who pulled that medication out of the pyxis for students? Did their instructor do that & then strand them or what?

2) I'm sorry your charge did that to you. I've only seen one nurse take on 3 students and she choose to do that because she can handle 3, she's also been a nurse longer then many people have been alive.