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Clinical Exemplar

Rachael Lewkowiez

University of South Florida

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Clinical Exemplar

A clinical exemplar is a way for nurses to demonstrate their clinical thinking and

judgment skills and how they affect patient care (Black, 1997). If nurses have no way to prove

their training and decision making is valuable, corporate healthcare organizations may choose to

replace them with less trained personnel at a lower cost. This is an example of how my decision-

making and critical thinking skills have benefitted my patients in my preceptorship on a Labor

and Delivery unit when I had an experience with staff-splitting in a difficult family dynamic.

When I arrived on the unit for my shift and looked at the board, I saw that my preceptor

and I were assigned to room 16. Based on the board I could tell that the patient was a full term

primipara, she was ruptured, and her last cervical exam was 5-6cm/80%/-3. This means she was

5-6 cm dilated, 80% effaced, and the fetus was -3 station. We received report from the night shift

nurse, which confirmed what the board said. Night shift also told us that the patient had come in

the previous morning at 0700 after she SROMd (spontaneous rupture of membranes) at home,

she was extremely anxious and that the patients mother was with her and the mother had been

very intense and controlling, and that the patient had an epidural but it had been very

challenging to get it due to the patients anxiety levels. We were told that they started the patient

on Pitocin at 2 miliunits per minute but the baby started to have decels in its heart rate and the

Pitocin was stopped immediately. We went into the room for bedside report, introduced ourselves

to the patient and her family, and the night shift nurse was telling us about the doctors plan of

care, and pointed out that the warmer had been checked for all of the safety equipment, there was

a step stool in the room, the LDR kit was in the room and the Pitocin bag was in the room

hanging but was not connected.

As the outgoing nurse was showing us where the bag of Pitocin was hanging, the mother

loudly stated, We dont want no Pitocin, we already said that! I smiled and reassured her that it

was not connected to the IV, but that she was just letting us know that it was here if we needed it

later. The night nurse also informed us that along with refusing Pitocin, the patient and her
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mother had refused the peanut pillow, which is a special pillow that we place between the

patients legs to help bring the babys head down in the birth canal. Then the night nurse left the

patient in our care. It would be valuable to note that the patient seemed extremely uncomfortable

even with her epidural, she could not rest or stay still in the bed, and was rating her pain an 8/10

with her contractions. I could tell that there was a problem because the patient was in a lot of

pain, and also the whole room had a very negative feeling to it. Everyone was very tense and

seemed very unhappy overall. We called out to anesthesia for a pain evaluation, and they came

and gave her a dose of medication in her epidural. 40 minutes later the patient was still in pain

and we called anesthesia back for another pain evaluation. As anesthesia is assessing her pain

levels again, they suggested that her epidural catheter may have migrated or may not be in the

correct space and suggest that if she is not getting relief that she may want to replace the epidural

with a new one. My nurse preceptor went to the med room to grab more IV fluids and I remained

in the patients room charting her pain assessments and charting on her fetal heart rate strip.

While I was in the room alone with the patient and her family, the patients mother proceeded to

tell me about how great we are and how much they like my preceptor and I and appreciate us

caring for them. She goes on for about 10 minutes about how horrible her experience was with

night shift and how rude and condescending the night nurse was and that they received terrible

care overnight.

I let her speak and when she was finished I told her that I was sorry that they didnt have

a good night but that we were going to do our best to have a great day today. I finished my

charting in the patients room and went out to find my preceptor. When I told my preceptor what

the patients mother was saying, and we together told the charge nurse so that she was also aware

that the patients were unhappy. This situation reminded me of a term that we learned about in

psych class, and something I had also talked about with our peds instructor in clinicals called staff

splitting.
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Staff Splitting is also known as black and white thinking, and is when a patient divides

people and things into good or bad, only being able to focus on that persons positive or negative

traits. According to (Townsend, 2008) staff splitting can be related back to extreme fears of

abandonment and engulfment. They recommend nursing interventions for patients exhibiting

these behaviors such as reassuring the patient that you will be available for them without

reinforcing dependence, and giving positive reinforcement for positive and independent

behaviors.

I believe my actions were appropriate with this patient because my response to her did

not give attention to her negativity towards the night staff, however I still validated how she was

feeling and reminded her that we would be there for her that day. I achieved the desired outcome

of addressing her complaints without turning against other staff. The patient didnt bring up her

issues with the night nurse again with us. I think I am now better equipped to deescalate unhappy

patients and visitors thanks to this experience.

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References

Townsend, M. C. (2008). Essentials of Psychiatric Mental Health Nursing : Concepts of Care in

Evidence-based Practice. Philadelphia: F.A. Davis Company.

Black, PJ (1997). Use of the clinical exemplar in performance analysis. Neonatal Netw.

16(5).PMID: 9325873