Don't Stress, Assess!

Head to toe assessments are a huge part of your job as a nursing student, and when you're just starting out in nursing school, they can be intimidating. Did I just hear crackles? Did I check all of the pedal pulses? Are these pupils 3 mm? Can I check them again?

When you're just starting out in nursing school, your head will probably be buzzing with background chatter about what you did and didn't do while you're performing assessments on patients, because this is one of the first points in nursing school that you really need to pull everything together and ask yourself a large succession of questions at once:

• What am I seeing/hearing/feeling?
• Is this a normal or expected finding?
• What does this mean for my patient?

And you're thinking these things over and over again with every little thing you assess.

Knowing that, walking in to do your first few assessments can be awkward, even scary, because on top of asking all of these things to yourself, many times you're also trying to build rapport with your patient and keep them comfortable - you're trying to hold a real conversation while having an internal conversation with yourself.

Here are a few tips about easing in to assessments:

Small-talk first. Ask about how they're feeling. Ask their pain level, you'll need it anyway. Ask how they slept, how they liked breakfast, if they had water or coffee with breakfast. All of these things are also part of taking your assessment and help you just as much as pulling out your stethoscope and listening to bowel sounds in a lot of cases.

If you can, ask your patient if anything seems "off" to them. This gives you guidance to where you might want to do a more focused assessment.

Assess often. Ask the nurse you're working with if you can help perform assessments on their other patients. Get report on those patients to get a little background about what you would expect to find, then go in and find it. Get over your fear and listen to those lung sounds. You don't know adventitious breath sounds until you've heard them on a real patient - you don't just hear stridor or wheezing. You see them having a hard time breathing. You have them telling you what it feels like for them. No single part of the assessment stands alone. The more you practice, the more you pick up.

Discuss what you find with your nurse outside of the patient room. If you can find time that works for your nurse, let them know what your assessment findings were, and ask if there was anything you may have missed. Read more about the patient to see if there's anything you could look at in more depth for your next assessment.

Assessment skills are something that grow and evolve with you as a nurse once you get hands and stethoscope and eyes on more patients. Don't let the fact that you haven't done many assessments stop you from assessing. Jump right in, and remember that your patient isn't just a source of different sounds - they're a resource of information. You're there to treat them, in order to treat the, you need to know how they're feeling, and if you want to know anything they feel that you can't pick up with your own senses and your patient is able to tell you, by all means, ask.

Making the Leap: Providing Care and Truly Caring

I was skeptical at the possibility of being truly moved by a clinical experience. I have been touched deeply by experiences in clinical - by a man at the veterans' hospital who was told his condition was worsening and only had a few weeks to live, and asked me to spend time with his wife to comfort her because he was fine, by a woman recovering from a brain injury after an accident because I was there the first day she was getting into a cardiac chair and I was the first person to bring her to the window and see the outside in months. I have been deeply touched by being part of moments like these in clinical rotations, but when I heard stories of other students actually being moved to tears by their experiences, I thought, Well, I'm sure they just cry easily. I don't think it gets much more intense than this.

Yesterday in clinical proved me wrong.

I was on the Pediatrics Unit, assigned to work with a very young patient who had suffered from a traumatic brain injury that left him with hemiparesis, loss of his ability to speak and respond, and do all of the things a kid his age takes pride doing - running and playing, using the bathroom on his own, eating his own food. The morning was a slow one - I struggled to figure out how I played into things. His parents were so on top of it, they were involved and active and aware, and hopeful above all else. The patient's mother, I found out, was less than a month from giving birth herself and still coming in and tirelessly spending time with her son. The patient's mother was always smiling, always positive and praising her son's ability to pick up his head, to roll, to kick his foot. She was just so full of love.

I felt somewhat awkward coming into the situation because this was actually what had caused me the most anxiety about starting my rotation on the pediatrics unit - having to be a nursing student, learning my way around things in front of parents who knew all of it already and would no doubt shake their heads at me for being such a newbie. I was terrified of not being confident in front of parents.

But these parents were amazing, the kind of people you could feel comfortable around. Even as I was acquainting myself with the tubefeeding equipment, they were happy to say how other nurses they had worked with managed to get the tubing around the special bed and hidden so that the patient wouldn't be able to swipe at it with his good hand.

After a particularly tough physical therapy section, I asked the mother how she was holding up as we walked back to the unit - simple things like if she was able to rest, or if she'd had time to herself to really process with what was going on, or if they had been able to talk as a family about how they could help each other through her son's rehabilitation journey. She talked about how she was tired but coping, and about all the things her son used to do before his injury. I got her some cereal, and checked up on her whenever I came in to do assessments or feeding with her son.

When my shift was about over, I went in to say my goodbyes, make sure tubes were flushed and tucked away until the next feed, and see if there were any last minute things I could help her with. She simply smiled, a little bleary-eyed, and said "Thank you for talking to me."

Thank you for talking to me.

The fact that something so simple had actually made a difference to someone got me right in the heartstrings, and I felt it - the familiar prickly feeling behind my eyes that meant if I didn't skedaddle soon, I would be bawling right in front of a patient's family.

I suddenly realized that something about clinical is truly, truly validating - more than just practicing skills and checking tubes, the act of genuinely caring and being involved with your patients gives you a reason to chug through nursing school, even at points when you feel buried under exams and deadlines. Days like this make you realize that it's truly more than just work.

Everyone's Your Cheerleader

Maybe this isn't universal. Maybe this is just a phenomenon in "nursing towns" where a bulk of the students in the universities are trying to get into nursing programs, and few of them ever actually get in.

I started off my pre-nursing/nursing journey in San Francisco, where universities are littered with jilted pre-nursing majors who were wait-listed or changed majors somewhere along the way and had to change paths. Actually being allowed the honor in a state university of changing your major from pre-nursing to nursing was something akin to a Nobel Peace Prize. I was accepted to two programs once I finished my prerequisites, but opted to move to Sacramento for nursing school - another "nursing town", as it turned out.

Nursing students have a few identifiers at my university - our scrubs, our name badges, and our sweatshirts with the word "nursing" emblazoned across the front, ten times bigger than the name of our university. What I've found since being a nursing student is that when I wear any of these on campus, or to the store for a quick something after clinical maybe, a lot of people put aside the fact that they don't know you personally, because they know nursing.

"Oh, you're in nursing school! You must be really smart!"

That one makes me really uncomfortable, because... well, yes, I've gotten good grades. Yes, I like to think that I'm smart and capable. But how do you respond to this compliment without sounding like an overblown pufferfish? My usual answer is normally, "Well, I study really hard all the time..."

Then, there's the obligatory, "When are you graduating?"

Now, I can answer that it's going to be within the year, and there is always a huge, bright-smiled congratulations that gives me immense warm fuzzies, but also a feeling of pressure. No screwing up now, I tell myself. I've already been congratulated for graduation, so I better deliver, even if I am never going to see this person again.

My favorite story, however, is about a Wal-mart cashier I met last year who was quite frankly intimidating. She was tall, a bit burly, with tattoos and a piercing stare as she rang up the yarn and groceries I was buying with my grandmother. No conversation, no small-talk, just awkward silence and no eye contact.

Then, all of a sudden, she happens to glance at my sweatshirt, and as she's ringing up the ten Yoplait yogurts that I'm buying, she mutters, "You in nursing school, girl?"

"Yeah," I manage to say in my surprise that she's actually speaking to us now.

"Graduating?"

"Next year," I say with a small smile. "Still a little way away, but I'm getting there."

"Man, I tried those prereqs and I couldn't even hack it for a semester. Get it, girl!" she said, suddenly beaming at me and offering a fistbump, which I return with pleasant surprise. She manages a "Have a nice day!" for my grandma and I before plastering her business face back on for the next customer.


Being a nursing student is something amazing, just as an experience. It feels like everyone's rooting for you, even when you're just stepping out of your house. You hold doors for old ladies at the store, they get a glance at your scrubs or your sweatshirts, and they smile and say they hope you take care of them one day.

It's amazing how people just come together and support others, and being a nursing student has been one of those amazing chances to experience that kindness and support from people.

Build Rapport on the Floor

I don't know about you, but when I first started clinical over a year ago, one of the most terrifying things for me was trying to figure out how to connect with the nurses on the floor. I felt - validly - that I was being thrown into a previously well-oiled machine and needed to figure out how feel like I belonged among the nurses working on the floor, even if I wasn't in the same place as any of them knowledge or experience-wise.

Over the course of my semesters in nursing school, I began to build up more and more comfort on different floors, and found that there was a certain set of virtues that helped me get along with the staff I was working with. Getting along with staff, as it turns out, is a huge part of your socialization as a nurse, and greatly affects your clinical experience. If you can maneuver yourself into good relationships with your nurses and preceptors, you increase the benefit you reap from your experience. That being said, I came up with a mnemonic for qualities which help you build rapport with the nurses on your floor during your time as a student: COOL FIRE.

Competent: This is can be a little intimidating. You're probably thinking, I'm a student, how confident can I possibly be?! And that's true to an extent. But what matters is being honest and realistic - tell your nurses what you can't do or aren't allowed to do ahead of time, and be competent in the things which are in your scope of practice as a student.

Observant: Just because you can't do it yourself doesn't mean you shouldn't be there for it. Don't hang around the nurses' station. Get on the floor. Follow your nurse into rooms. Interact with patients and get to know more about their conditions from their perspective. Be a sponge for information.

Opinionated: Note that there is a difference between being opinionated and being a pain. Live up to your role as an advocate for your patients. Discuss with your nurse if you see something different from what they see, speak up.

Low-Maintenance: Nurses on the unit have a job to do. They are on the clock, and their job is to take care of patients, not to take care of you. Don't be oversensitive if they can't chat or sound a little snappy at times.

Friendly: As much as you can while still being professional, try to be kind to the nurses you work with. The fact that they are taking time out of their shift to contribute to your education, even if you never really get a moment with them besides when you introduce yourself at the beginning of the shift, is a big deal. Be respectful and kind to them. Be open to small talk on the floor among the nurses, especially if they are comfortable enough with you to include you.

Intuitive: Practice being a mindreader. We all have the ability. At least, we should have the intuition and tact to know that when our nurse is running late on meds or assessments that we should save our question for later. If they tend to forget saline flushes when going into a room, come in behind them with a couple and offer them up unobstrusively. Show that you genuinely are paying attention to them and want to help them.

Resourceful: The nurse is not the only person to bother. The unit has an entire healthcare team, and while they all have jobs to do, they are also people you can listen in on and learn from. The RT, the PT, the radiologists, the residents, even the custodial staff, all have input that you can hear and learn from.

Eager: This is important. Do not be a shrinking violet in clinical. Your experience will be what you make of it, and if you shrink away from every opportunity to practice new skills, observe new procedures, or see new, interesting, and yes, sometimes difficult patients, you will miss out on so much that is at your disposal in clinical. "Can I do that foley?", "Can I d/c that IV?". As long as it's within your scope of practice, reach out and volunteer with confidence.

Trying to embody these qualities as a student can be intimidating. It can be terrifying. But clinical is the time that you can come out of your shell as a member of the healthcare professions and really bask in your chance to have a safe environment to learn, and to help people in the process.

A Good Instructor Makes All the Difference

Throughout all of my education, motivation has been something I have struggled with. My schoolwork has always gone down the pooper when I've felt disinterested or disillusioned by whatever I was doing, which I think is my biggest fault. It's the reason why I take on extra projects and research - because there are times that I need to strive just to keep myself interested enough to put in the effort.

I had thought nursing school would be the end of that problem, but low and behold. My second to last semester in nursing school, and I found myself in one of my worst slumps that I have ever experienced.

I started off the semester in my OB rotation, and I already knew coming in that Labor and Delivery would not be the niche. I would never strive to be on this floor, and I would never have a passion for it. This was different from all other semesters, where I walked in with an open mind to every Med/Surg and ICU floor that I rotated through. I even got myself excited and involved in the GI lab, where all I did for an entire morning was assist with colonoscopies and endoscopies. But on Labor and Delivery, I already knew that my heart would not be here.

What made things worse was that our clinical instructor was a flop among flops. I spent an entire 6-week rotation never getting feedback on what I was doing, or even getting comments on my assignments. She rarely spoke to us when she saw us around the floor, and when you needed to ask her a question, she was nowhere to be found.

Over the course of that rotation, I began to feel that familiar feeling of simply hating what I was doing. I'm not going to get through nursing school, if it's like this the rest of the way, I thought to myself. I simply felt myself spiral into an old pattern of losing motivation and not putting in effort because I simply had lost my passion for what I was doing. I had come prepared to at least learn a lot in the rotation, even if I knew I would never come back to labor and delivery floor unless it was to have my own child one day. But I knew that I wasn't learning. Our teacher did not expect knowledge from us, and she was far too disconnected to give us any either. I would try to approach her, have conversations with her about my day and my patient as she was sitting at the nurses' station, sitting and looking around at everyone and not talking - but the effort to engage with her just never paid off. I was simply there on the floor, going through the motions, and for the first time, I was sure that I hated nursing school.

And sure enough, it started to show in my grades. For the first time in all of nursing school, I didn't pass a test with the 73 we needed. I flopped with a 71. My heart sank - but I didn't know what to do. I was trying to study. I was trying to care. But I simply couldn't engage with anything we were doing, and it started to show in all of my classes. The average of my exams was passing, but hardly. As a student, I was hardly recognizable - the motivated, ready-for-anything girl that all of my previous instructors knew had turned into this shrinking violet who hardly felt compelled to do anything.

Getting out of my OB rotation is probably my saving grace. I just started my Pediatrics rotation yesterday and met my new instructor.

I came in last out of anyone else because I had been waiting for my pain meds to kick in - I had spent the previous day in the ER and found out I had an ulcer, which I will swear up and down was because I stressed myself out trying to figure out how to bounce back from a failed exam grade. I came into the room, and my new instructor just beamed at me and genuinely seemed to mean it without the slightest trace of sarcasm when she said, "I'm glad you made it! Are you okay?"

My new instructor is funny and engaging. She found me working on charting at different times throughout the day and worked with me, talking through what I would want to look for in my patient, who I had just been assigned that morning. She gave me pointers on how to approach nurses on the floor so that they would let me do more things. She was honest in her criticism, but also generous with her praise.

And I felt horrible and amazing all at once, because I realized that she was motivating me in a way my OB instructor had in no way been able to, and it hit me as I finished up my shift for the day what a rut I had gotten myself into, because I realized the way I felt at the end of the day with this instructor was a complete 180 from the way I felt at the end of the day with the other. I realized in a flash just much I had lost just because I wasn't motivated.

There will be instructors that you love, and instructors that you hate. There will be instructors who make you want to do your best, and others who make you wonder why you do this at all. The real lesson comes in being aware, and reaching out when you need to. I made the mistake of not reaching out for other instructors' advice and mentorship, when I had an entire school of nursing at my disposal. And that's an important part of being a nurse - knowing your support system and using your resources.

So - use them. Make connections to an instructor or an adviser who inspires you, because the instructor you have may not always be the best motivator for you. Put yourself in a position to succeed, and surround yourself with people who can help you.