It’s here…you’ve finally made it to your fourth semester and the clinical rotation you’ve been dreaming of (hopefully) since Day One. Your nursing school preceptorship. Making the most of this very valuable time can pave the way to a successful transition from student to new-grad RN. And, chances are, you’ve got a lot of questions. Lucky for you, you’re in the right place.
What should I focus on during my nursing school preceptorship?
There are three things you should focus on during your final clinical rotation: prioritizing, time management and assessments.
As an RN, you are constantly adjusting your priorities based on your patients’ constantly adjusting needs. The patient who starts out “the sickest” could easily become your most stable patient as you meet their needs and other patients develop NEW priorities.
As you prioritize, think about the following:
- What data do I need RIGHT NOW in order to care for this patient?
- If I don’t act on XX RIGHT NOW, will the patient suffer harm?
Let’s say you have a patient who “found down” for an unknown period of time. His urine is cola-colored and he has a decreased LOC. He’s pulled out his IV and is too confused to take anything PO. What are your priorities?
- Get an IV in there STAT. A patient in rhabdomyolysis needs LOTS of fluids in order to save the kidneys from total and complete failure.
- Monitor urine output amount and color. As the renal function improves, urine output will improve and the color will start to trend toward yellow.
- Monitor labs: BUN, CKs, creatinine, electrolytes.
So, you’ve got the IV in place, fluids are running and the patient is making urine. Phew! At this point, your priority shifts to routine things like safety (is he crawling out of bed?) and comfort (is he in pain?). But let’s say he suddenly gets short of breath, and his O2 sats drop to the mid 80s. What’s your priority now? Yep…lungs.
Maybe all that fluid he’s been getting is a little much for his ol’ ticker. You listen to his lungs and lo-and-behold he’s sounding pretty wet. Now what? You still need to hydrate for the kidneys…but the extra fluid is backing up into his lungs. Whatcha gonna do? Yes, you need to protect the kidneys, but your patient also needs to breathe.
- Lasix? Maybe, if urine output is inadequate…be careful with elevated Cr though
- Dialysis? If the kidney injury is severe, then this is a possibility
- BiPAP or intubation until the fluid clears? Very possible if other interventions aren’t sufficient
What data do you need?
- Get a CXR to see how fluid-filled the lungs actually are and maybe also an ECHO to determine the ejection fraction (a measure of cardiac function)
- If it’s been awhile since you got a BMP (including BUN/Cr) check those out. Is the kidney function getting worse? Does he need dialysis?
- Assess his respiratory status. Is he tachypneic with increased WOB? Maybe he needs BiPAP…or maybe he’s buying a ticket straight to intubation.
So now he’s being intubated, and while you’re at it, the NP decides to pop in a central line. But guess what? It’s his first central line and he causes a pneumothorax. Oops! NOW, what’s your biggest priority? Getting that chest tube in STAT! See how priorities change as your patient changes?
Keep in mind that nursing is a fluid, dynamic process. How your shift starts is NEVER an indication of how it will end 🙂
Time management is easily one of the toughest things to master…and it’s universal, whether you work with 5 stable patients or 2 critically ill ones. My best advice is to come up with a system for tracking TWO key things for each patient…what you need to DO and what you need to CHART.
To accomplish this, I use a “run sheet” that I devised for ICU. It’s essentially two columns…in the left column I write down what I need to DO. I fill this out as much as I can at the beginning of the shift and add things to it as they come up. In the right column, I write down things “on-the-fly” that I need to chart later.
Here’s how it looks at the end of the day. As I chart the items I wrote down in the right-side column, I’ll check them off so I know they’re officially done.
Note that this is just ONE way to manage your time. When I occasionally get floated to telemetry and I have FOUR patients to juggle, I use a sheet with four columns and across the top I include: patient last name, room number, code status and admitting Dx. Then I use the area in the column to put all my “to-do” and “to-chart” items. I don’t have a sample of this as it’s something I just make up as needed…but you get the idea 🙂 Want more time management tips? Here you go and here you go again!
Do all your head-to-toe assessments with your preceptor and discuss what you are hearing, feeling, seeing in real time. Not sure you’re feeling crepitus around that chest tube? Get a second set of hands on there. Is that mottling you see? Are those breath sounds worse than they were this morning? Discuss, discuss, discuss.
And in the ever-useful words of my first semester clinical professor…be accurate and be thorough! Get your eyes, hands, ears and nose on as many patients as you can. People are all different shapes and sizes, and they all sound slightly different. Knowing what’s “normal” vs “abnormal” is KEY to being a competent new grad RN.
Here’s a little review of 5 key assessments every nursing student should master!
What if I don’t get placed in my “dream unit?”
In two words, “don’t stress.” Though it would be GREAT to precept in your dream unit and then get offered a job there…this is a RARE occurrence. Use this time to focus on building your three basic skills and I promise you’ll get the most out of it as you possibly can. If you want to work with kids and get placed with adults…that may be a bummer, but you will still learn a LOT.
I wanted to precept in ICU, but there weren’t enough ICU spots for students. So I took a spot in telemetry (on NOCs…ugh!) and used this as an opportunity to work on my time management, priority and assessment skills. I practiced giving awesome end-of-shift report and doing things like starting IVs, placing Foley catheters and knowing what constitutes an emergency. I watched my preceptor as he constantly changed his priorities based on his patients and assimilated that into my own practice.
To sum up…WHERE you learn isn’t nearly as important as WHAT you learn.
How can I evaluate my progress with my preceptor?
If you are taking your preceptorship seriously, then you want to seek out useful feedback so you can gauge where you are and what you need to do to get where you want to be. Use these questions as a guide when you discus your progress with your preceptor.
- What could I do to strengthen my assessment skills?
- I’d like to become more adept at writing narrative notes and charting, can you provide feedback?
- How could I improve in regards to time management?
- I realize prioritizing is important, can you identify my weaknesses in this areas?
- What feedback can you provide about my communication skills…both with patients and the medical team?
- Am I seeking out appropriate learning opportunities in clinical? Where am I falling short?
How can I make connections for my job search?
Whether you are precepting on your “dream unit” or not, you should ALWAYS treat each and every day at your preceptorship as a job interview. Even if that unit isn’t hiring, wanna bet that the charge nurses and manager know the charge nurses and managers of other units? Here are a few things you can do to leave an impression so that A) you can compete for a new-grad job on that unit or B) you can start building your network of people willing to provide you with a solid recommendation:
- At some point early on, introduce yourself to the director of the unit. A simple, “Hi, I’m Mark. I just wanted to thank you for having me here for my preceptorship and look forward to learning as much as I can while I’m here.” Don’t ask for a job, don’t ask about job prospects, just say howdy and show your appreciation.
- Let your awesome work ethic shine through. A “can-do, will-do” attitude goes a LONG way toward making a good impression.
- Ask intelligent, thoughtful questions to show your interest and your thought process. Your preceptor will appreciate this peak into your brain and know you are willing to seek out information (the know-it-all nurse is never a popular nurse).
- Accept feedback and criticism gracefully. This means instead of saying, “Yeah, but….” you say, “I understand. Thank you.” If you truly need more clarification, then say, “I’m not sure I understand. Can you explain the rationale?” or “Can you explain in more detail? This isn’t something I’m familiar with.”
- If a patient/family pays you a compliment, shamelessly ask them (or have your preceptor ask them) to write the manager a letter singing your praises. This works WONDERS for making a positive impression come job-hunting time
- At the end of your preceptorship, bring in treats for the unit to share (yes, this is expected of you on your last day!) and make sure you once again approach the director and personally thank him/her for having you. It is perfectly acceptable at this time to say, “Do you foresee hiring any new grads in the near future? If so, I’d love to work here and you can anticipate seeing my application when the time comes.”
Where are you precepting? What tips do you have to share with others? Let us know in the comments below!