Who supervises you during clinicals?

[calivianya, BSN, RN]

Just curious. I graduated last May and have been working as a RN since July, and what I am seeing at my current job is shocking and horrifying to me. The way my clinicals worked at my school is that 6-8 of us would be assigned to a clinical instructor, and that clinical instructor would be with us on whatever floor we were assigned to. If we were on a cardiac med/surg floor, all students would be on the cardiac med/surg floor and the instructor would usually be at the cardiac med/surg nurses' station if she was not helping a student with something. It was also required by the hospital that the clinical instructor had to be with students when they were giving medications, so any actions they took were technically under the instructor's license and not the license of the nurse taking care of the patient for the day. Also, we were assigned patients in advance and required to come in the day before to look up all of the patients' diagnoses, make care plans, and make drug cards with all of the patients' medicines and what they did so we knew why we were giving each medicine and had a good idea of what the patients' disease processes really looked like.

Now, where I work, I see rogue students all the time. I call them rogue because there may be 4 students in ICU, 4 students on med/surg, etc. and I have yet to ever see a clinical instructor. I have no idea whether their instructors even exist or if the students are just thrown to the wind. If the student wants to do something, it has to be with me in the room and I am forced to be a teacher because there is no instructor to be found. Fortunately, I do work in ICU so I can afford to spend more time in each patient's room and explain some things to these students, but really - what the heck is their clinical instructor being paid for if I am doing all the teaching and all of the supervising because the clinical instructor is nowhere to be found? I have other things to do besides teach, and I can't spend all day explaining things to students when I have two patients and the corresponding doctors, family members, and paperwork for both to handle. Oh, and the student just gets report from the nurse and that's all he/she knows about the patient. There is no coming in the night before and looking up diagnoses. Literally, I have had students have no idea what any of the patients' medicines are for or what the normal disease process of the person in the bed is. Really?!?! I am very uncomfortable with this situation, and now that I have seen this in action, I am not surprised as to why this particular school has a reputation for turning out horrible nurses who don't know anything. Why should they know anything - they are thrown to the winds with no instruction but whatever the bedside nurse feels like she has time to teach that day, and not everyone takes kindly to having a student because it eats up so much time. I think it's horrible and the school should be shut down if that's the best they can do. I know they have been in danger of losing their accreditation in the past because of poor NCLEX pass rates. It's scary stuff. The only time I was left alone without an instructor nearby was in my preceptorship, when I worked 36 hours a week with the same nurse. That's all good and well because she got to know me and my abilities, but these students I only see once and never see again. How am I supposed to make good decisions on their knowledge and abilities when I only have them for a few hours?

I do let students do things. I let one prime the tubing for me and load the IV pump - and she was a senior about to graduate and said she'd never had the opportunity to do that before. What in the world?!?! That's terrifying.

So, tell me - what does your clinical day look like? Who is supervising you? Are you actually being taught, like I was in my clinical experience, or are you just thrown in hoping someone gives you a chance to do something?

[nynursey_]

When I was in school, my clinical group consisted of 10 students on a small Med/Surg floor. We were there for 5 hours at a time. Only one student a week did a med pass, and it was typically 1 med pass. If a procedure came up, the instructor had to be present. If she wasn't, we lost out. Skills were practiced in the lab and rarely at clinical. I graduated with virtually no hands on experience. None.

[Rose_Queen, BSN, MSN, RN]

Way back in the day (let's just say about 10 years ago), we were closely supervised until our senior year. Then, the instructor was responsible for the same sized group, but we were scattered to different units- some in ICU, some in step down, some in ER. Obviously, the instructor can't be everywhere at once, but we were also allowed to give PO/SQ meds and continuous fluids on our own with the nurse.

As for the "working under the instructor's license", that is a complete fallacy. From Iowa:

Nursing faculty frequently talk about students practicing under a nursing instructor's license. This is an inaccurate statement because the only person who works on a nurse's license is the person named on the license.

Nursing Practice Acts include statutory language that specifies what are called exemptions or exceptions to the requirement for a nursing license. Typically, practicing nursing as a student who is enrolled in an approved nursing program is one of the exempted (or excepted) practices. The nursing student is accountable of nursing actions and behaviors to patients, the instructor, the facility and the nursing program.

The accountability for nursing instructors is for their decisions and actions as an instructor. For example, the instructor is accountable for the selection of patients for the nursing students' assignments. The instructor is expected to support studies preparing for the clinical experience and to monitor students' clinical performance. Most critically, the instructor must intervene if necessary for ther protection of the patients when situations are beyond the abilities of the students. Instructors must identify "teaching moments" as well as assess and evaluate the students' clinical performance.

The broader accountability reflects the education, experience and role of the instructor, who is accountable to the patient, the student, the facility, the nursing program and the professional licensing board.

From Texas:

[h=2]Are students practicing under someone else's license during clinical learning experiences?[/h]The nurse student is not required to have a license under the exemption in the Nursing Practice Act 301.004(6) but can practice in a student nurse role under the supervision of a qualified member of the nursing faculty for purposes of meeting educational requirements for clinical practice. Since the student nurse is exempt, he/she is not practicing "under the faculty member's license."

Essentially, students are responsible for their own actions. Instructors are responsible for selecting appropriate patients for those students, but unless they ask the students to do something completely out of their scope, they are not liable for the student's actions. Many schools either outright require the purchase of student Liability Insurance or incorporate it into the cost of tuition.

[RunnerRN2015, ASN, RN]

Starting in 101, we have 6-8 in our clinical group plus the instructor. Our clinical experience sounds similar to yours except we're allowed to do all med passes (except IV meds) on our own (depending on the clinical instructor). Once we've been checked off on setting up IV pumps, trachs, and wound care, we can do those on our own as well. If we have IV meds and our instructor isn't present, we can administer them under the guidance of our nurse. We log into the computer system under our student ID and chart everything we do, including meds. Our instructor goes in and validates everything at the end of the day. We rarely practice skills in the lab because we can do them on the floor.

[Everline]

For my first two semesters, we were in a clinical group of about 8 students with one clinical instructor. We all stayed on the same floor and our clinical instructor had to be with us to give meds. That meant that about half of us (or less) would get to administer meds on a particular day, as we had patients with a large amount of meds. This semester our clinical instructor sends us in all different directions. I have never been supervised by her. I do not see her all day. We are on our own, basically. I have not given any meds this rotation, nor done anything invasive.

[mrsboots87]

I just had my first clinical last week. My facility has 2 floors and the students are split between the two. The instructor goes back and forth between the two to supervise. We go in up to 2 days earlier for patient research and to start our care plan. Then the day of, we work with our assigned patient for assessment and whatever else the patient will need that day. If it's just ADLs and CNA duty stuff, we can work with the CNA. But if it is meds, or wound care, and such we have to be with the RN or our instructor. We have PO checkoff this Thursday and injectable checkoff next Thursday. After passing those we can pass meds to our assigned patient only and it has to be with the instructor the first time and all following times can be with the RN. After the instructor has seen us perform tasks (outside of med admin) we can practice those skills on our own on any patient who needs it, but are primarily responsible for our assigned patient. So basically, we are aloud to follow the RN and request to practice skills if the RN has time or is ok with monitoring, but if not then we have to ask our instructor. And things that require sterile technique or are a little more complicated has to be supervised period. Our clinical sites would probably end their contracts with the school if they acted like the one at your facility. That's craziness to just be free to roam with no instruction. Especially since they seem to be behind for their level. We will be learning IVs next semester, so I would assume I will be expected to have had some experience with them by my final semester.

[mrsboots87]

Oh, and there are 10 students per clinical instructer per facility per day.

[smoup]

We have 6 in my clinical group and an instructor. We are all on the same unit and the instructor is there with us for all meds and anything else that needs to be done (FS, hanging IV's, etc). If the nurse on the floor wants us to do something an the instructor isn't around, the nurse can supervise if they wish or can do it themselves.

[flyersfan88]

I'm in my preceptorship for my capstone class and my instructor is not involved. However, never have I at any point come in the night before clinical to research patients, and I dont find that I've suffered for it.

[ruralnurse84]

Our clinical groups are 7-9 students per instructor. Half of the students are on the floor with the instructor for half of the quarter, the other half are in ancillary groups dependent on the nurses of that floor to teach us for that day. However, it is nothing such as you have described. I have never had a problem on the ancillary units and the nurses on the units are usually welcoming and willing to teach. They know at the start of the quarter that we are coming and are given a list of the skills we are allowed to do with and without supervision. It is usually a department within the hospital that our instructor is on, although we do go to hospice, outpatient surgery centers and endoscopy centers that are stand alone facilities. For the floor days with our instructor we have 2-3 patients, get report that morning, and do all our care of the patients...honestly we make the work a little easier for the nurses except when we need med check offs or supervision for certain procedures. We try to use our instructor as much as possible for the supervision but occasionally need the nurses. Our school has very good pass rates and most of our students do a good job on both the floor and ancillary units. I don't know what would happen if all 7-9 of us were on the floor at one time...I don't think we would get any actual practice in.

[Jenngirl34RN]

My clinical group is 7 students. My clinical instructor has to be on the floor with us at all times (we all take lunch together), and she wansers around and checks up on all of us. We can pass meds or do other things we have learned in lab with the RN we are assigned to, but only after we have done it with her first and she has determined we are safe and know what we are doing. It doesn't matter if we have done something a hundred times in lab, we cannot do it in clinical, even with RN supervision, until the instructor has signed us off.

[ArrowRN, BSN, RN]

What you (the OP) describes sounds similar to our experiences. I'm a senior BSN student and there is a bit more autonomy. There is actually lots more to cover so the instructor will not be with us all the time and we are a large group. We work directly with the nurse on the shift in the ICU and will not come in the day before as the patients change quickly. We barely have 30mins on the day of the shift to get all info not to mention getting used to the hospitals computer and charting system, so finding that info can be daunting, hence the reason why we may not know it all.

Considering you've been less than a year out there, it might be something you want to bring up with your charge nurse, to not have any student assigned to you if you are uncomfortable with this, after all it's your license on the line and your patient. I don't know if that is the case or if the more experience nurses at your hospital are just unwilling to help.

I can tell you one thing though, we students really appreciate you taking the time out to show us stuff. The instructor cannot be there every time for us to have experiences and if an RN is unwilling to help then our learning goes down the toilet and we graduate knowing nothing. But its really up to you if you want a student to do something and you observe them, its appreciated. We understand this slows down the RN but most of it is just nerves of doing stuff for the first time...we all had a first time.

If you don't have the time, we also understand that part also. I totally get what you are saying, but from a student view, sometime RN's just don't want to be bothered by us. It's really no surprise when some graduate they end up being lousy nurses...and guess what, they going to be your coworkers some day.

Yes the instructors has a part to play but so does experienced RN's.

Edit: now if the student if just being a bloke and is working on the cardiac floor and doesn't have the sense to look up basic cardiac meds or at least the class of meds the night before well then that's just the student being lazy and unsafe.