Who supervises you during clinicals?

[calivianya]

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?

[GemTwist]

Just finished another med/surg clinical. 8 students between 2 floors and 1 clinical instructor. We have always had to come in early to research our patients, write care plans, list/know meds, understand patho, and understand the pt's labs. This all has to be checked by our clinical instructor before we can begin care. We do full assessments and chart them. We have to pass meds with our instructor for the first time each different route then we can pass with the nurse. For any procedure (PICC bandage change, IV cath placement, wound dressing change, urinary cath placement...etc) we have to do it with our instructor first then can do with the nurse if the nurse is ok with it. Some days we come in and one of our pt's has been discharged and we get a second pt that morning and we just have to do a brief write up on them with meds....which can be easily looked up on micromedex. The hospital we were just at also sent out a reminder to the nurses that students are NOT practicing under their license. Also, if I were you. I would ask the student what the med does, is, and side effects....if they can't answer then they can't give it. Our instructor can not be evrywhere at once. You sound pretty stressed so maybe bringing it up with your charge about not having students. The nurses I worked with this clinical were so great compared to previous. Even though they had 6 pt's and were busy. I would tell them I uunderstood how busy they were and I would try and stay out of their way and if they didn't want to be slowed down by me passing meds or whatnot there would be no hard feelings. Most of them still took the time with me to pass meds when my instructor was not around. You may bring up your concerns with your charge regarding lack of preparredness of the students and also bring it up with those who handle the education/clinical set-up.

[CrazyGoonRN]

My RN school experience was very similar to the OP's, but my LPN school experience was a lot like the students she has at her work place. In LPN school my clinical instructor would sit in the conference room with her laptop and work on her graduate school homework. We received very little direction. We were told to follow the nurses but the nurses expected us to be getting direction from our clinical instructor. I don't blame them. I expected to be getting direction from my clinical instructor also, but didn't. It was not a good situation.

[SopranoKris, MSN, RN, NP]

We have 8 to a clinical group and 1 instructor. He stays on the floor with us. Half the students pass meds on day 1 and the other half on day 2. If we do any skills, the instructor must be present or we can't do it. If we're lucky, we're assigned to a nurse that likes having us there and lets us do as much care as possible for the pt. Sometimes, you get a nurse that considers students a nuisance and you're basically relegated to standing in the hallway, begging for something to do. When I have days like that, I jump in and help the techs after all my paperwork is complete.

As we go through each semester, there are more things we're allowed to do on our own. Meds, however, must always be with the instructor. Our last semester, we are assigned total care for the entire shift. Should be interesting :)

[HouTx, BSN, MSN, EdD]

Hmm - seems to be a great deal of diversity here in terms of exactly what the Clinical Instructor is responsible for.

I totally agree with the OP & understand her dismay at being forced into the role of a CI. It would be different if the CI actually met with or 'rounded' on the students to make sure all was well, but it doesn't seem as though there is any communication between the CI & staff nurse who is working with students. To me, this raises some questions. If the CI is 'delegating' teaching responsibilities to the staff nurse, shouldn't this have the same requirements as a normal delegation model which requires (at minimum) that the CI would make sure that the staff nurse was competent in this capacity? Also - how in the world is the CI evaluating student performance if there is no observation or interaction with the student--- crystal ball???

Hopefully, organizations are conducting periodic formal evaluations of the teaching process which would enable them to provide feedback on CIs to their respective schools. If not, this is a disaster in the making.

[calivianya, BSN, RN]

Wow, thanks for all the replies. It's been really interesting to see how varied everyone's experiences are!

I think HouTx has hit the nail on the head for me - I have never spoken to a clinical instructor. I have no idea how competent these students are. And while I almost always let them do most things for me so they have experience, with me standing there watching, I still don't know their strengths and weaknesses and have to almost "over-supervise," if there is such a thing. I'll be sitting there hovering and explaining step by step... but I have to, because I have never seen these students before and I have no idea what they know. Also, the students I see typically are there from 3-11, which is a whole different source of exasperation because we work 12s, and they don't get to start out and plan their day... they just walk in when one nurse is almost finished anyway and then see the first part of my shift, so I only have a couple of hours at most to teach them. I don't feel like there is any continuity in what they're experiencing. I spent all two hours of that time with a student last week walking through the basics of mechanical ventilation and explaining the unusual mode my patient was on, but I got so far behind doing that that I left late that day. Never caught up, and didn't have the opportunity to get things done and then answer questions, because they were about to walk out the door and I wanted to make sure they understood that particular mode because it was something we don't see all that often and it was something I never saw at the other hospital I used to work at. That student asked a lot of questions about pressure vs. volume, PEEP, whether proning would be appropriate, etc. and it was a fun experience to talk over, but it really is a pain to get hours behind on my charting just to teach.

I would love to have the clinical instructor talk to me about the students so I know them better, and hence it would be great to see the same faces more than once. I really like teaching - I thought for a while that I was going to major in English and be an English teacher. I like teaching people who *want* to learn, anyway. It just sucks to have no baseline idea of what the students can and can't do, no list of tasks they need to do (that I know of), etc., and it also sucks explaining basic meds to them that I feel like they should know by the time they hit their senior year. It is just a bad situation. I brought it up with my charge last week but that's just how things are done, apparently. No one seems concerned enough to make any changes. I think this is a classic case of "this is the way we've always done it!" which is totally not a valid excuse.

[ArrowRN, BSN, RN]

Seems like that school's clinical coordinator needs to plan better with the hospital as far as objectives. We were told that our RNs or at least the charge RN gets a list of our learning objectives for the clinicals or at least has some idea of our skill level, not individually but as a group. Some hospitals also have a specific list of things they would allow nursing students to do and not do. In any case students work under the instructor's license so it's really his or her responsibility to ensure everything is coordinated and running smoothly (if there is such a thing). Planning these experiences sounds like a nightmare.

[moabgirlie]

First semester 10 students, 1 clinical instructor, 1 hospital, all floors. We went the night before and researched information, met prior for pre conference and afterwards for post conference. Our instructor assigned us to a patient and to a nurse. The nurse asked what we had passed off and then was our sole supervision. Our clinical instructors rounded through the hospital checking on us, but never for longer than say 5 minutes.

The next 2 semesters, 10 students in a group at a hospital, spread throughout the floors, units, ER, and same day. Fast pre conference with over an hour (second semester was like 3 hours) long post conference. Again, assigned a nurse as primary supervision, no real research or "patient loading" before hand.

Last semester precepting (capstone) assigned 1 nurse for > 135 hours. 3 meetings with clinical instructor over the course of a month.

At no time in 4 semesters were we ever allowed to pass meds or do anything more than CNA type duties without direct supervision of our nurse or preceptor.

As far as being able to look up meds, labs, disease course, care plans etc... to me it's almost more of a crutch and I'm glad we only did it that first semester. How often do you get anything more than a 3 minute bedside report and a glance at a patient's Kardex or chart before you just have to hit the floor running?

I like to glance at labs, med lists, and orders quickly just so in my mind I have a basic idea of what I'm dealing with but I rarely get anything more than that.

[IThinkICan100]

Last semester I did fundamental clinicals in a hospital and the 12 of us were divided up by departments (so there were two or three students to a department). We were just put there each under a nurse and our clinical instructor would float to the different departments. It seemed to work out fine. I did have any problems because I previously worked for that hospital, so the entire staff knew me (and let me in on the good patients!).

This semester is gerontology and we were previously in a nursing home (scheduled for a half semester or 6 clinicals) about a hour away from our university. We were in one department and in groups of two with each of the groups assigned to one patient. Our instructor would just float around and come as needed, mainly because we were just doing CNA work and didn't need to preform nursing skills. Well, that instructor had been teaching at my school for 10 years and this was her last semester. SOOO.... She decided to bad mouth the university and tell us that we were in a reject school (among some other things), so they cut her clinicals from the schedule and the dean told this instructor off! ...YIKES!

Next week we are starting at a post acute care facility with our main professor as our instructor. This professor is excellent and we all love her, so I think we will have a great time! Very excited!

[la_chica_suerte85, BSN, RN]

I think that may just be symptomatic of that school. Here's how it works at my school:

-We practice skills a few weeks before work at the clinical site starts and it is repeatedly clarified to us (written and verbal) which skills we are allowed to do under RN supervision (i.e. G tube care) or strictly under instructor supervision (i.e. passing meds).

-At the hospital we're on a med-surg unit but, being we only have one instructor, only a few of us are with her at one time while the remainder of us go to other clinics/units. When we are in these other places, we are there to observe and do what is asked of us within the scope of the skills (not meds) the RNs want us to do (so, basically we do nothing but observe).

-As stated above, we aren't under the license of anyone. We have to purchase Liability Insurance through the school every year to stay in compliance and in case we make any royally terrible errors.

-Apparently it used to be the case that we would go to the hospital the day before to get the pertinent info on the pt but that is no longer allowed for whatever reason. We get the chart, get report, look up meds we are giving that we are unfamiliar with, and then procedure from there. My instructor is exceedingly strict that we look up the meds and Dxs prior to making contact with the patient.

Again, I really think it's just that the school bringing in those students is terrible. It's really up to your hospital to kick them out. We are held to a really high standard and are reprimanded immediately if we do anything not in line with what the hospital wants of us. We are at the mercy of the hospital for them to allow us to be there, the hospital is under no obligation to host us or any school that does not abide by their standards and P&P.

[tkg123]

I have recently completed two different clinical rounds at two different hospitals. One hospital we were allowed to do almost everything with the nurse we were assigned to, including passing meds (IV too!) after being checked off on the skill with our clinical scholar (a nurse from the hospital with special credentials for supervising students.) We were also split up onto 3 different units. At the other hospital, we were allowed to pass meds and perform assessments(but not chart them) and perform most other skills and treatments with our nurse. We were not allowed to pass any type of IV medication without our instructor present at the second hospital. Here we were all on one floor. Our instructor was available to assist and did go in with us to perform new skills or just to help us when our nurses had pressing issues (time, emergencies, etc).

[auralae]

My current clinical experience sounds nearly identical to how your clinicals were. We are in 3rd semester- we have class all day once a week, and then that afternoon we drive to the hospital to get our patient information. The night before clinical, we fill out a "clinical prep" document, complete a medication prep, and then three times during the semester we complete a full-blown FPAT form & CPG along with the SBAR & regular charting that we do weekly. We are only allowed to give meds after checking off with our instructor, and then we are only allowed to give PO's alone without her (or our team leader's) presence. Our instructor will not clear us to even give a PO med if we are not prepared, or if she does not feel that we are competent to do so. Our instructor is on the floor *at all times*. As far as med passes, since we are currently on a pediatric floor, we have to research safe doses for our patients to verify what has been prescribed. I feel that our group does a fantastic job of being prepared & providing patient care- but with that being said, I can't imagine not having our instructor on the floor. That just seems horribly unprofessional to me.