Case Scenarios

Consider the following scenario:

Elizabeth is a third year nursing student entering clinical for the first time. In simulation lab she has learnt about IV infusions, patient hygiene, injections, patient assessment and monitoring of PCA (patient controlled analgesia) and oral medication preparation and administration prior to entering clinical placement.

Elizabeth becomes upset when she receives the following comment during clinical evaluations. “Elizabeth is a hardworking and committed student but needs to work within her scope of practice and focus on consolidating skills appropriate to her level of enrolment”.

Elizabeth was asked to describe her clinical placement and what prompted this comment from the Clinical Instructor. Elizabeth states that she had a great clinical placement and was given many great learning opportunities by the nurses on the unit. She had been permitted to perform IV medication preparation and administration, perform central line dressing changes and monitor a patient who was receiving PCA.  She was proud to have learnt skills well beyond those of most of her colleagues and stated that she was upset that the Clinical instructor did not support her initiative. 

  1. What is the main problem in this scenario?
  2. Why is this scenario concerning?
  3. What steps could have been taken to ensure that Elizabeth was working within her scope of practice?

Let’s re-think our scenario from the view of the instructor:

Mary is Elizabeth’s third year clinical instructor.  She has only been an instructor for a couple of terms however she has worked on this floor as a nurse for more than 20 years.  She is aware of what skills Elizabeth has learned in the classroom and laboratory settings prior to starting her clinical rotation.

When the rotation started, Mary clearly outlined the expectations of the clinical experience as well as reminding the students what they were allowed to do as a third year student.  Mary reviewed the scope of practice as outlined by the University and the hospital.  It was apparent from the start of the clinical rotation that Elizabeth was an ambitious student and was keen to learn new things. 

Elizabeth’s enthusiasm, however, became a potential problem as the clinical rotation progressed.  Mary overheard one of the nurses discussing how ‘advanced’ Elizabeth was as she was able to start IVs as well as mix IV meds on her own!  As it was time for a mid-term evaluation, Mary felt this needed to addressed and documented on Elizabeth’s evaluation that: “Elizabeth is a hardworking and committed students but needs to work within her scope of practice and focus on consolidating skills appropriate to her level of enrolment”.  Mary also requested a meeting with Elizabeth to discuss the report.

In this meeting, Elizabeth stated that she had a great clinical placement and was given many great learning opportunities.  She also stated that she couldn’t understand what the problem was and was disappointed that her own instructor was not please with her work because all the nurses on the unit were.

  1. Did Mary do enough to ensure Elizabeth was practicing in her scope?
  2. Did Mary address this issue soon enough?
  3. Do you agree on how Mary addressed this issue?
  4. Are there any other individuals involved in this case?
  5. Is there anything else Mary could do? 
  6. Could Mary’s lack of teaching background have contributed to this problem?

Another very important thing that needs to be remembered is that the clinical instructor carries the additional burden of accountability—ensuring that each student is providing safe and effective nursing care within their scope of practice. 

If something would have gone wrong when the student, Elizabeth mixed and started IV’s, many would have been accountable, including the clinical teacher, Mary.