Students (especially those with no healthcare experience) often experience some feelings of uncertainty and doubt when starting clinical. First of all, I want you to know this is totally normal. In fact, it’s a good thing! Being a little anxious about performing well in clinical simply means you care about your education and your patients. So let’s agree that you’re going to give yourself some grace and accept the fact that what you are feeling is to be expected.
But, of course, I know you want some actionable steps you can take to actively feel more confident in your clinical rotations. Here are my best tips for feeling confident in clinical. If you want to get this information on the go, tune in to episode 164 of the Straight A Nursing podcast.
Show Up Prepared
The first step to feeling confident in clinical is showing up prepared. This means completing all your clinical prep work ahead of time and making sure you have all the necessary equipment to do your job. The main items I suggest you bring are a stethoscope, two to three pens, a pair of hemostats, a pair of scissors, a clipboard for your clinical paperwork, a brain sheet and something to help you organize your day (like my “Run Sheet”). Some students find badge reference cards to be helpful, or you could simply carry a small notebook that contains your own notes on must-know information (pediatric vital signs, for example).
Know What to Expect
Do your homework ahead of time so you know what to expect from your clinical experience. What type of unit is it? What is the normal patient load for a student at your level? What is expected of you? Will you be passing meds, testing blood sugar, assisting with ADLs, taking vital signs? All of the above?
Review Any Relevant Skills
Prior to your clinical day, review any skills you anticipate you might need. Foley catheter insertion and removal, IV removal, dressing changes, and NG tube insertion are all common skills you may get to practice. I promise that you’ll feel so much more confident practicing on a real person if you’ve taken a moment to go over the steps the night before.
Know The Common Medications for That Unit
Medication administration is one of the highest-risk skills you will be required to do, so it’s important that you be familiar with every single medication that you give. A great way to get a jump start is to review the the most common medications for that particular unit. For example, if you are heading into a surgical unit, then know your opioid and non-opioid pain medications, reversal agents, and stool softeners. If you’re on a neuro unit, know your anti-seizure medications. Heading into labor and delivery? Then you’ll need to know oxytocin, magnesium, terbutaline and misoprostol (just to name a few!).
Play The “What If” Game
One of my favorite ways to assuage my pre-clinical anxiety (and even when I was working as a new grad nurse) was to play the “What If” game. I would think about the top two to three scary things that could happen with my patient. While “what if he codes” is always going to be The Scariest, try to really think of things that pertain to your patient’s particular situation. For a surgical patient, you might think things like:
- What if he hemorrhages?
- What if he gets too much opioid and stops breathing?
- What if he gets a DVT and pulmonary embolism?
Then, just do a quick run-through of what you would do as the nurse in each of those situations, thinking of the things you’ll do to PREVENT the situation as well as how you would REACT if it did happen:
- What if he hemorrhages?
- I’ll keep close eye on blood pressure and heart rate. If blood pressure drops and heart rate goes up, I’ll investigate further.
- I’ll watch for hematoma development and check underneath the patient for pooled blood.
- I’ll keep a pair or clean gloves at the bedside so I can quickly put them on and apply pressure.
- I’ll call the surgeon STAT and stay with the patient so they remain calm. (A student would let the RN know STAT).
- What if he gets too much opioid and stops breathing?
- I’ll monitor his sedation level every two hours as required by hospital protocol.
- I’ll assess sedation level prior to any additional opioid doses.
- I’ll perform assisted ventilation with the BVM if necessary and call a “respiratory code.”
- I’ll give naloxone per facility protocol (a student would not likely give naloxone, but you’d let the RN and your clinical instructor know so the appropriate intervention could be done).
- What if he gets a DVT and pulmonary embolism?
- I’ll make sure the patient wears his SCDs when in bed.
- I’ll ambulate the patient three times per day.
- I’ll make note of any unilateral leg swelling or redness.
- If the patient complains of sudden SOB with dropping O2 saturation levels, I’ll sit him in High Fowlers, put on oxygen and call the physician or Rapid Response Team STAT (if you’re a student, get help in there STAT…let the nurse know!)
Plan and Prioritize Your Day
Participating in change-of-shift report is crucial to getting an overview of the patient’s needs, outlining their current issues and keeping a consistent plan of care in place. Make sure you use a report sheet and practice using as many abbreviations as you can…those nurses talk fast!
Once you’ve received report on your patient, take a moment to look up some key information on each patient. The more adept you can get at navigating the EHR, the faster this will go. The key information you’ll want to obtain for each patient is:
- The most recent MD progress note
- The most recent RN progress note (often an “end of shift summary”)
- Labs (looking for abnormals and those most relevant to the patient)
- Key orders such as dressing changes, PT, activity restrictions or orders, diet orders/restrictions, blood glucose checks, etc…
- Meds that are due (just jot down what times they’re due so you can plan and prioritize your day
Next, make a quick list of each patient’s main problems or risks. Jot down 2-3 things you can do to address each of these. For example, let’s say you have a patient who had abdominal surgery…what are their main problems or risks? And what are some simple nurse-led interventions that address each one?
- Pain relative to the surgical site
- Administer pain medication
- Teach the patient to use a splinting pillow
- Encourage distraction activity such as a television program or visitor
- Risk for DVT (due to immobility)
- SCDs while in bed
- Ambulate three times per day
- Teach the patient to do ankle pumps while sitting in the chair
- Risk for pneumonia (due to immobility, lack of coughing/deep breathing…it hurts!)
- Manage pain
- Teach patient to use incentive spirometer
- Ambulate three times per day
Guess what you just did with that list? Created a care plan! Look at you go…doing nursey things!
Next, start jotting things down on your “run sheet” indicating when you’re going to do key things for your patients. Meds, blood sugar checks, ambulation, dressing changes, etc… Don’t get too detailed with this. As you’ll soon learn, even the best laid plans quickly get tossed out the window when actual “real life” happens.. But it’s good to at least start with a plan so you can begin your day with a basic structure. Refer back to this plan throughout the shift so you can continually prioritize your care while ensuring those “must-do” things actually get done. Pay careful attention to timed interventions such as medications and make sure you understand the administration time guidelines for your facility and your nursing program. If a med is “due” at 0900, you may be able to give it in the hour before and after 0900, or it may be a smaller window such as thirty minutes before and after. And yes, “late” meds can be cause for failing clinical…so don’t skip this very important step!
Commit to DOING as Much As You Can
Honestly, what you get out of clinical is directly equal to what you put into it. Get in there and DO as much as you can, even if it’s a skill you’ve done six times already…get in there and DO it. You’ll soon learn that things don’t always go as planned and that, my friends, is when the real learning starts. On that seventh time you hang some tube feeding, maybe the tubing will clog, or the pump won’t work as expected, or the patient will start coughing up something that looks suspiciously like tube feeding. Now you’ve got to do some problem solving, and with that comes a whole lot of learning.
On the flip side is the skill you’ve never done before but you’re too scared to try. Scared to do it wrong, scared to look incompetent or nervous in front of the patient, scared to look uncertain in front of your clinical instructor. Guess what? This is how you learn! Take a quick moment to review the skill by either looking it up in the hospital’s policy library or in Lippincott’s Manual of Nursing Practice (which your facility may subscribe to online). Then, gather your supplies and go in there and do it step-by-single-baby-step with your resource person by your side. Trust me, they want you to succeed…and so does the patient! Everyone will be rooting for you (me included!).
Realize You Are There to Learn
Many students view clinical as The Ultimate Test. And while it is the place where you put all the pieces together, if you view it as an 8 or 12 hour exam, you’re going to burn yourself out before the end of your first week.
Give yourself permission to be a STUDENT. Give yourself permission to be in LEARNING mode. If you think you have to have all the answers, you are setting an incredibly unrealistic expectation for yourself. It’s okay to not have all the answers. However, if you don’t have the answer it’s not enough to just say “I don’t know.” The correct answer is, “I don’t know, but I will find out.” Know your resources, know how to look up policy, know how to look up your meds or access information in the patient chart. You can’t know everything, but by golly you know how to find it!
Keep a Clinical Journal
One of the fastest ways to 10-X your clinical learning is to use a clinical debrief form or clinical journal. By reflecting on what you observed and did in clinical, you can then take that information and apply it to future situations. For example, when your patient is short of breath, watch what the nurses and respiratory therapists do. Notice what orders the MD writes. Pay attention to how the patient responds and how the team prioritizes the interventions and assessments. Then, when you’re faced with a patient with respiratory difficulty, you have some background clinical experience to draw from.
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So there you have it…my best tips for feeling confident in clinical!
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