My college has instituted a new program this year. For the last two weeks, our normal classes have been suspended while we participated in a "clinical immersion." This immersion involved working a minimum of 45 hours over two weeks one-on-one with a preceptor. It has been a useful but extremely frustrating experience. To be honest, if I had had this experience at the beginning of nursing school rather than now at the end, there's a good chance I wouldn't have continued in nursing. Or, if I had, I would have been a lot more motivated to memorize and also to practice skills in the skills lab, which I haven't done once during school (didn't seem necessary!).
I have included below the e-mails I sent to my faculty supervisor to update her on my experiences. I have changed some details in order to protect the privacy of the innocent victims of my care. If you read these, you will note my struggle with time management. I am convinced this is the result of BSN programs' failure to provide enough bedside clinical training. My max patient load previous to the immersion was two ambulatory patients for 6 hours. While I was doing the immersion, students in the final year of an associates degree program were working alongside me on the same hospital unit. They were all managing 4-5 patient assignments for an entire shift with ease.
As I have suggested before on this blog, the rationale behind the BSN program is not oriented toward producing work-ready floor nurses and this needs to change. I have no intention of going into management or research, and neither do any of the other students in my program. If professional leaders in nursing want the entry-level nursing degree to be a BSN, they need to face the fact that the BSN program needs to change in order to accommodate the different educational requirements of the floor nurse. University courses in research, management, and professional issues need to be bumped up to the MSN level. Research skills need to be changed from performing research to assessing its value and validity. The assessments course needs to be more focused on acute care unit skills rather than primary care skills. Focus on patient care planning needs to be changed from creating extensive documents to using them in the acute care setting. More clinical hours are needed.
Here's my schedule for the last two weeks:
Tue = met with preceptor
Wed = 7a-7p
Thu = off
Fri = 7a-7p
Sat = 7a-3p /3p-11p work
Sun = 7a-3p / 3p-11p work
Mon = off /3p-11p work
Tue = 3p-7p
Wed = 7a-12p
Thu = off
Fri = 3p-11p
Subject: Re: immersion experience
From: Chris xxxxxxxxxxxxxx
Date: Fri, April 24, 2009 10:40 pm
To: "Zoanne Schnell, PhD, RN"
It's very hard. I met with my preceptor Tuesday morning. My first day was Wednesday, a 7a-7p shift with 3 patients til 3p, then 5 patients 3p - 7p. Yesterday (Thursday) I read the book "Shadow Cities" by Robert Neuwirth for Nur425 Community Health. Today (Friday) I worked 7a-7p with 5 patients. Tomorrow I am back at 7a again and then again Sunday at 7a.
Since the most patients I've had in clinicals up to this point is 2 and the most hours I've been on the floor is 6, it's quite a change. I haven't been able to manage them all by myself, and my preceptor is pulling a lot of weight (doing the admissions today), but I improved a lot today from Wednesday, and I am confident that I will continue improving throughout the weekend.
I'm not sure what my schedule will be for next week. My preceptor is out of his regular shift Tuesday for the hospital's "practice council." I don't know if he works Wednesday or Thursday. Then Friday he is definitely on 3p-11p.
The biggest problem I'm having is keeping track of everything in my head. For example, when it comes time to report off for the next shift, I can't remember where every patient's Saline Lock is or what every patient's cardiac rhythm is without referring to the flowsheets. I'm trying to deal with this problem by creating a worksheet for myself to take notes on and will trial it tomorrow.
One problem I'm having is lack of exposure, although I guess this is to be expected as a student. For example, today I heard course rales for the first time and couldn't quite identify what it was since I've only heard relatively fine rales in previous clinicals. Also, I described a patient with liver failure as being extremely jaundiced, which caused some eye rolling since, apparently, the patient was only mildly jaundiced.
However, in another instance, I thought a patient was doing very poorly on Wednesday when no one else was concerned. That night, the patient declined and the priest was called for last rites, so my intuition in that case was correct.
Some critical thinking skills are lacking. For example, I could identify an ACE-I correctly today, but failed to figure out that it was for CHF. This was a case where, if I had known the patient's admission history as before a normal clinical, I would have pieced everything together. But forced to think on the fly under stress, the connections aren't quite there yet.
My charting was very weak Wednesday. Today was better, but my notes need a lot of work.
I have to keep reminding myself that I'm still a student. It's frustrating that I can work for 12 hours with only a 20 minute break for lunch and be behind when I can see that there are nurses who have time to sit at the nurses' station. Somehow, I'm losing a lot of time around the 3p shift change, but I don't know how.
Will keep trying...
Subject: Re: immersion experience
From: Chris xxxxxxxxxxxxxx
Date: Mon, April 27, 2009 10:31 pm
To: "Zoanne Schnell, PhD, RN"
Well, Saturday was a disaster, but Sunday went okay. On Saturday, I had a 5 patient assignment 7a-3p. My last 9a med pass didn't get completed until 11:45. My preceptor said it was a busy day, and we did have a scheduled paracentesis and unscheduled thoracentesis going on in the same room, but I still thought the day should have gone more smoothly. My overall charting was better but my event notes were not good (this is by my own assessment, not the preceptor). I worked that night 3p-11p and then went back Sunday for 7a. On Sunday, I had a 3 patient assignment and an admission. The day went textbook and even my notes were better, but of course it was a very light assignment.
I find that I spend my time trying to treat the computer and flowsheets rather than the patient, which is very frustrating.
My notes need a lot of work, and I think they indicate my thought processes aren't well developed. In one case where I thought a patient's mental status was deteriorating, I had taken into account a number of assessments but the event note was discombobulated, so my thinking processes weren't systematic. I think an assessment has to be systematic before severity can be assessed properly.
Anyhow, I'm hoping I can manage a 5 patient assignment 7a-7p on Wednesday, but the CCC students will be on R-3 as well, so I suspect I will only get 2-3. That will leave only 3p-11p shift left in my immersion.
Subject: Re: immersion experience
From: Chris xxxxxxxxxxxxxx
Date: Wed, April 29, 2009 10:11 pm
To: "Zoanne Schnell, PhD, RN"
I had a longer response, but when I hit the send button a few moments ago, I got logged out of webmail. It looks like it didn't go through...
Anyhow, 4 hour shift Tuesday, whole shift today, but my preceptor was charge nurse so I went home early, and 8 hour shift coming up Friday. Should have a total of about 56 hours not counting time as charge today.
Tuesday went well with 2 patients and 2 admissions.
Will update again after work Friday...
Subject: Re: immersion experience
From: Chris xxxxxxxxxxxxxx
Date: Sun, May 3, 2009 9:11 pm
To: "Zoanne Schnell, PhD, RN"
So, last Tuesday, my preceptor's shift was 7a-7p, but CVPH's "practice council" was 7a-3p. I considered attending practice council, but decided against it. I worked 3p-7p in the step-down part of R-3 with a 2 patient assignment, and I received two admissions during that period as well. My patients and admissions were stable, and this was a fairly easy shift. The thing that really stood out for me was that my preceptor had already completed and charted his shift assessments when I was starting on them. I don't even know how he did it. I was with him for all but a few moments at the beginning of shift, and I'm shocked he could do them so fast. So, I must be losing some time on my assessments. My preceptor said they are thorough, however.
On Wednesday, I was planning to do a 7a-7p shift, but when I went in to work, my preceptor was assigned to charge. I stayed until noon, but I wasn't really learning anything and felt I was in the way so I went home. As charge, I received charge report in the AM, attended a STEMI alert (similar to a code) in the emergency room, took a patient who developed an active GI bleed to the ICU, and participated in patient rounds in step-down. However, as a unit clerk on R-3, I have been working alongside the charge nurses for a number of years and already have a clear idea of their normal work day, so there wasn't much to get out of a charge experience.
On Friday, I worked 3p-11p. Unfortunately, this, my last shift, was the worst time I had during the immersion. I had a 6-patient assignment that I performed mediocre until my 9p med pass. Up to that point, I was struggling a little to keep up, but things were getting done. But I started the 9p med pass at 8:40 and didn't finish until about 10:50. During that time, I had one distraction, which was a temp spike in a patient that required a call to the MD. So, I was averaging about 18-20 minutes per patient. I can't figure out why it was taking me that long, although one thing is that it seemed like every time I went in a room, the patient and the roommate both had other things they needed me to do for them. Not sure how to manage that without essentially ignoring the patients.
However, the real problem was that when I noted how long it was taking me to get the med pass done, I started to get anxious and make mental errors that I might not have made otherwise. One was a med error. A patient with a QVAR inhaler had another patient's Symbicort inhaler in the med drawer along with an empty bag for the patient's QVAR inhaler. Not knowing what the inhalers look like, I assumed the one in the drawer was QVAR and since the barcode for the computer scanner is on the bag instead of the inhaler itself, the computer didn't catch the error, either. This was an easily preventable error since the name of the patient and the name of the med are printed on the inhaler, and since QVAR doesn't take a spacer, which was attached to the Symbicort inhaler. If I had been less anxious about finishing, I might have thought to check the inhaler or wondered about the spacer. The error was caught because the patient asked whether s/he was going to receive QVAR, too, AFTER s/he used the Symbicort inhaler!
The other mental errors I made had to do with (1) being rushed and forgetting, or (2) taking the word of others instead of verifying for myself. I had three post-cath patients, but one of them (post-procedure day 2) didn't get his groin site checked during the assessment because when I mentioned the groin site, s/he said s/he didn't have one. I assumed I must have been mistaken about it rather than looking for myself, then forgot to check my Kardexes to see who the third groin site was. In one of the other patients, the patient had several Q1hour groin checks left before the Q2hour groin checks started, but the aide doing vitals told me the Q1hour checks were done. I believed him instead of verifying for myself. Then, on that same patient, I completely forgot about performing the Q2hour checks when I got behind in my med pass. That patient also didn't receive regular turn-and-position care. In one patient, I forgot to perform a BID dressing change that I had planned to do after the med pass.
The med error was annoying, but I am really bothered at forgetting about the turns and groin checks on that one patient. Then I didn't complete the report off to the next shift until 11:25, although we kept getting interrupted. I stayed after the shift and went through all my patients med drawers to organize and order missing meds from the pharmacy. Also, although my paper charting (R-3 still uses paper flowsheets) was completed in time, my computer shift assessments didn't get done until after my shift was over. Very frustrating night, and I didn't go home until about 1am. Really, staying any more than a few minutes after end of shift is not acceptable.
It's unfortunate that this was my last shift since my self-confidence took a real blow. I have some trouble with focus and organization in general. I've always been afraid these would manifest in difficult patient assignments, and they did. In fact, right now, I feel like I'm not sure this a career I am capable of doing. I need to get back in and do a couple 4+ patient assignments adequately before I'll feel like doing anything but hanging my head. I am also extremely worried that I did something wrong on Friday that I am not even aware of, and I've been experiencing a lot of anxiety over going back to work as a unit clerk on Monday. What will I find?
Anyhow, it's over now. Will have to wait and see what my preceptor's assessment is.
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