1. Facente, Alice C. MSN, RN-BC


A nursing instructor finds herself in the hands of a challenging former student.


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I was having trouble breathing as I lay on that gurney in the chaotic ED. Was it a result of my fear? Or did I have an unseen pulmonary injury?

Figure. Illustration... - Click to enlarge in new windowFigure. Illustration by Annelisa Ochoa

I had been in a car accident. I was in pain, and the cause of my pain was obvious. My neck hurt, my tibia poked through the skin on my right leg, and my right foot looked mangled and bloody. The reason for my fear was more complicated. Although I'd been a nurse for more than 20 years, this was the first time I had been so completely dependent on the health care system. I felt vulnerable. I knew too much. I needed to feel confident that the ED nurse assessing my injuries would do a thorough job and give unqualified support to a fellow nurse-turned-patient.


In walked the nurse who'd be caring for me. I stared at her. She looked familiar, like a slightly older version of a student I'd taught in the past. Even though the movement of my neck was restricted by a cervical collar, placed there by the emergency medical technician who brought me to the ED by ambulance, I managed to glance at her name tag. It was indeed Angela.


My mind raced back five years. It was my first year of teaching. I had eight students in that first clinical rotation, and seven of them were anxious and hesitant to actually touch the patients. Angela was different-in fact, she was somewhat confrontational and challenging. I didn't doubt her comprehension of the pathophysiology of disease; she'd aced her written exams. But applying theory to practice requires patience and critical thinking. Angela had been impulsive and impatient. She didn't seem to realize how crucial a careful, comprehensive patient assessment could be.


Worse, Angela tended to brush aside my admonitions. Because the assessment parts of her care plans frequently lacked critical data, her nursing diagnoses and interventions were often incomplete. When I had my individual conference with her, I explained my concerns and reviewed my written evaluation, which specified where improvement was needed.


But Angela was unconvinced. She rolled her eyes when I urged her to slow down and take greater care with the vital nursing process. I overheard her telling one of her classmates, "She's always picking on me because I'm young and quick."


I felt that my concerns were valid, but I also questioned my competence as a first-year instructor. Should I pass her? Or should I fail her, which would ultimately result in her expulsion from the nursing program? I slept poorly for several nights as I weighed the options. I consulted a faculty colleague who had similar concerns about Angela. I didn't want to be responsible for passing a student who'd be impetuous and careless-the results could be devastating. At the same time, I felt Angela could become an excellent nurse-she certainly had the potential. But passing or failing her was my call. Nursing students are truly at the mercy of their clinical instructors.


And now I was at her mercy. I had to put my trust completely in Angela. I asked if she remembered me. She laughed as she said, "Of course. How could I forget you?"


Her response only in creased my apprehension. But she had a calm, soothing voice, and she was careful and deliberate as she began her assessment, proceeding from head to toe as I had taught her. I began to feel slightly more confident. As she systematically auscultated all of my lung fields, she asked, "Does this hurt? Can you take a deep breath?" She gently, skillfully palpated every inch of my abdomen, asking, "Does that hurt? How about this?" By the end of her assessment, I felt she'd become an astute and precise clinician. I heard her quietly give a comprehensive evaluation of my condition to the ED physician.


Angela came to see me in my hospital room after I was admitted. We talked for quite a while. She told me that I'd given her a wake-up call during that first clinical rotation. She really had listened to my warnings and admonitions and had begun to exercise more careful judgment. She said it took her a while to overcome her resentment of my criticism but later came to realize the value of that clinical experience. (Luckily, my accident occurred after she came to that realization!) Angela had matured into the kind of nurse I'd suspected she was capable of becoming five years earlier. I'd taken a calculated risk. What a relief to realize that giving her that passing grade was indeed the right call.