Journal of Nursing
Keeping a Positive Outlook: My Clinical Experience as a Student Nurse
by Ashley P. Cohen, Student Nurse, Massachusetts College of Pharmacy & Health Sciences School of Nursing, Class of 2011, Boston, MA. Acohen2435@yahoo.com
An attitude is an important thing. It can shape the way the individual sees an experience and how observers see the individual. An attitude can entirely make or break an experience. This is as true in clinical experiences as it is in life. My experience in my senior year clinical preceptorship was without a doubt unique but I feel its uniqueness was in what I made of it, something every nursing student can do for themselves. If there is one lesson to gain from reading about my experiences it should be that the success of a clinical, whether a preceptorship or group experience, is entirely what the student makes of it.
My first day I walked into the ICU and almost ran right back out, thinking “Get me out of here!” It was a 10 bed unit, the traditional glass ICU room doors, two crash carts at either end of the unit, patient charts seemingly everywhere, precaution carts, glucometers, IV poles and pumps, doctors running into the room at the end of the hall, telemetry monitors beeping and spitting out rhythm strips. Little did I know these sounds and sights would eventually become more calming than frightening. I kept thinking to myself how was I, a student, going to handle a clinical placement on this floor? My last medical surgical clinical had been the previous summer, it was now March, how could I possibly remember the necessary skills to be ok here? What if I forgot the important skills? I had been in the same group of large Boston teaching hospitals for every other clinical experience, now I found myself in a small 95 bed suburban hospital. “A Paper chart… this hospital uses paper charts?” was another of my first impressions. I met with my preceptor, a nurse with 30 years experience. I was intimidated. She let me know that I would work towards covering her patient load, with her supervision of course. I would also be expected to know my dosage calculations and all of my medication facts; she let me know that “robot nursing” was not how we would handle things. Nurses around the floor began to tell me that she had taught many of them and that she was tough but I would learn a lot. To a new student this was reassuring but hearing that she was nicknamed “sarg” only added to my mounting fears of this experience.
On my first day we met at the patient assignment board to receive report from the night shift charge nurse. She methodically went through each of the patients on the board, “Patient presents to emergency department unresponsive…” “Patient intubated and heavily sedated…” “Patient on Cardiezem drip” “Patient in septic shock, treating with Xigris drip.” Hearing this certainly didn’t help my nerves. My first patient was on a ventilator, in congestive heart failure and acute respiratory distress syndrome (ARDS). We went into the room and my preceptor told me to “get started.” I froze. Then, suddenly it came to me, “we always assess first,” and I did my head to toe assessment. I remembered this from one of my first nursing classes, Health Assessment. “Ok” I thought, “I remember how to do this.” My preceptor let me know I forgot the check pedal pulses. “Darn” I thought, how could I forget something like that? My preceptor reassured me, it was my first time doing a full assessment in a while, and forgetting one thing was “not a big deal.” As the day went on she allowed me to complete more and more tasks. We went to get 8 am medications; she quizzed me on each of them. By 11 am I was deep suctioning my patient on the ventilator. I was learning ventilator settings, what was PEEP, PIP, Ftot, Fi02, VT, VE, and what the numbers that went along with each meant physiologically. I also began to learn what each of these numbers meant for my patient’s health. Little did I know that five days later I would be extubating this patient as his family moved him to comfort care only. Little did I know that later that same day I would be performing the post mortem care on this patient. I learned quickly that I would need to adjust to the pace of the ICU, as I had to adjust to every other floor I was on for clinical. Each floor has its own pace, its own rhythm, and as a student we must become a part of the flow, not obstruct it or try to work against it.
Another patient I had during my experience was a woman with COPD who was in end stage heart failure. She was another ventilated patient, slowly I was becoming really good with these ventilators. I wasn’t messing up on my head to toe assessments. I could fill out those seemingly silly paper charts. I was figuring out where to find things in the supply room. After a another few days my patient was able to be extubated. As she began to gain consciousness a lively 70 year old woman came from someone who had been a living version of my anatomy book on the bed. She would eventually tell the nurse and me that she wanted to be moved to comfort measures only and hospice home care. She let the nurse and I know that she wanted to go home to smoke and drink her vodka until she passed away in peace. I learned that we don’t always like our patient’s decisions, but we must respect them.
One of my last patients was a man in severe septic shock; a complication of a prostate biopsy. He had what seemed like ten medications going in IV lines at any given time, not including all of the fluids they were piggybacked off of. He had two peripheral IV sites as well as a right internal jugular central line for his infusions. A problem came up however; he wasn’t putting out any urine. At one point his input was somewhere around 1600ml to a 15ml output, his output became a huge cause for concern, someone being fluid resuscitated and not putting out urine, I began to wonder about his kidney function. Another part of my education I began to appreciate, all of my classes were coming together, I was thinking systematically. I watched as a team of nurses and doctors tried to save this man’s life. We ran blood cultures times what seemed like a million, a urinalysis, ultrasounds of the heart and kidneys, EKGs, CPK/Troponin levels, serum blood levels, and electrolyte levels among other things. Then I began to hear my preceptor say “start the bicarb in the distal port” “what is his output?” “let’s get him on the cooling blanket” “get a set of vitals,” I was being actively involved in this critical patient’s care. Although I was petrified I kept a positive and open attitude. I thought, “I can do this, I have been here for four weeks, I know how to do this.” I was practicing skills I had learned back in my old, at the time outdated, basement nursing lab. These skills I thought were long lost somewhere in my memory were coming back to me, just as the cliché says, like riding a bike. As unprepared as I had felt going into this clinical experience I slowly began to realize that I was prepared and I did know what I was doing.
Knowing what I was doing surprised me. How could a few labs and clinical placements on an orthopedic floor, a labor and delivery floor, a detox unit, and a general psych floor help me be prepared for the acuity of patients on an ICU? I couldn’t believe it. Every single clinical experience, every single lab, and every single clinical simulation helped. The smallest skills I learned in clinical and lab, those skills that seemed so easy that I wondered if the professors were questioning my mental capacity, became the skills I used on a regular basis, the ones that made the biggest difference in my practice. You think making a bed is so easy? Try doing it with a six foot, five inch man who weighs 250lbs and getting the sheets straight because he’s sedated and you don’t want to risk skin breakdown. You think oral care is a joke to be learning about in lab? Tell that to the patient with oral candidiasis who wants nothing more than a swab to keep his mouth comfortable. These little things make an enormous difference to even the most complex patients. Again, the attitude in learning these skills should be a positive one. You want to provide your patients with the best care possible, in order to this you must start by practicing the best possible skills in clinical, lab, and preceptorships. Every day in clinical presents a new challenge, you will come upon things you didn’t even know you were afraid to do, but with the help and guidance of a preceptor or clinical instructor, you will get through the experience and be better for it. You should seek out these challenges, and do what scares you. If it scares you now imagine what the feeling would be when you have that “RN” or “LPN” at the end of your name, those little letters making you responsible for your patient’s care. As students we need to advocate for ourselves, gaining as many experiences as possible before we graduate and are on our own. Expose yourself to as much as possible. If a nurse down the hall has a patient getting a procedure done, ask to watch. If another nurse’s patient needs a dressing change, ask to do it! Be determined, remember to wake up thinking “I get to practice for my career today,” don’t go in with the “ugh, I’m tired, why do I have to be here” attitude. Remember that your education is your choice. Nobody will force you to attend clinical, sure there are consequences for not going, but ultimately the decision to be in school and to attend clinical is the student’s.
We all get tired, we all have challenges outside of school, but with a positive attitude about learning and a little determination to succeed we can all get through any clinical experience, learn a great deal from it, and enjoy the learning. I can’t say it enough; any clinical experience will be what you make of it. Two students in the same clinical group can have incredibly different experiences if one goes in positively and the other negatively. Nurses will notice who the students are that want to learn, they will seek you out to teach you if they think you want to be taught. There will always be the one intimidating, scary, or “grumpy” nurse on the floor. From my experiences I have learned that they usually can be won over if you show them that you are a serious student, there to learn from them, not to judge the way they practice. If nurses notice that you are just stuck on autopilot, doing only what is absolutely required of you in clinical, they won’t have an interest in teaching you, and why should they?
They say life is what you make of it, well, it is my opinion that the same is true for clinical and preceptorship experiences. The more you as a student advocate for yourself, the more experiences you gain exposure to, the better nurse you will be. You will be more prepared for your eventual practice and feel more comfortable joining the professional world. Remember that you are more prepared for clinical than you think. You will make mistakes, we all do, nurses with years of experience still make mistakes. The important thing to do is look at your mistakes, learn from them, and move forward. Keep a positive attitude and realize that you are learning. Never be afraid to try a skill again just because you made a mistake, you should in fact force yourself into this experience again, so that you know you can do it. It would be hard to find a nurse who didn’t miss trying to insert a catheter, but with practice we all become comfortable with it. You didn’t stop trying to walk after your first fall, did you? Skills will come with time and practice. You will be scared; there will be days you want to quit. There will be days you will question if nursing is for you. Over time these days will become few and far between, and you will feel the rewards of nursing. A patient’s thanks and appreciation will make all the hard work worth it. In regards to mistakes, my preceptor had this to say for all students, “It’s the learning curve, none of us (nurses) are expecting you to be perfect, we’re just expecting that you try your hardest and show us you want this.” So remember, we’re students, not super heroes, we won’t be perfect, but with a positive attitude, we can make any experience a great and rewarding one.