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Nursing Handbook Section 5: Clinical and Laboratory Policies

Appeal of Withdrawal for Unsafe Clinical Practice or Unprofessional Behavior

The first step in the formal process is to provide a letter to the clinical faculty within seven days of the occurrence of the concern. It is important that the initial letter includes a written statement of appeal as well as a cover letter. It is suggested that the student retain a copy of all correspondence. The letter should contain a clear outline of the history of the incident(s) including a review of the problem and actions taken to avoid or resolve it. The student(s) will be notified of the decision in writing by the clinical instructor within seven calendar days from the date of the letter.

If not satisfied, the second step is to submit the appeal to the Clinical Coordinator, if the clinical instructor is not the clinical coordinator. The student will be notified of the decision by the clinical coordinator within seven calendar days.

Finally, if the student is not satisfied, he or she may contact the Director of Nursing within 10 days of receiving the clinical coordinator ruling. All materials and communications from previous contacts in the procedure should be assembled by the student and forwarded to the Director of Nursing with a cover letter. The cover letter should contain information which describes the situation in detail as well as the resolution sought.

The Director of Nursing will convene a committee composed of no more than 5 faculty other than the clinical instructor and the Clinical Coordinator. The committee includes at least one tenured faculty.

In addition, one student will be selected from those who have expressed an interest in serving on an appeals committee. The student will be from outside the complainant’s level. A graduate student may also be invited. He or she will be a voting member.

The committee will provide the student and the clinical faculty an opportunity to discuss the circumstances surrounding the incident. The Director of Nursing will be a nonvoting member unless there is a tie. The committee will issue a decision following the meeting. Notification to the student will occur in writing within seven calendar days from the meeting. The decision of the committee will be final.

Depending on the committee’s decisions, the following sanctions may be imposed:

  1. Verbal reprimand without an entry on the student's personal performance record.
  2. Written reprimand with an entry on the student's personal performance record.
  3. "F" in the course on his/her permanent transcript.
  4. Other actions as deemed appropriate by the committee.
  5. Dismissal or denial of re-entry.

Clinical and Laboratory Policies

The clinical laboratory session is a learning opportunity where the student is expected to utilize all resources to extend the learning experience. During the clinical laboratory class, or at any other times, students may not practice invasive procedures on other students. Simulations and models are used for invasive procedure skills practice.

During some experiences, such as physical assessment, students may be expected to act as models. If a student has any objection to providing this experience, they should notify the instructor immediately so that an alternate experience can be provided.

As opportunity permits, clinical instructors facilitate student responsibility for learning, encouraging or requiring such activities as student participation in the selection of learning experiences, sharing of personal learning goals, keeping an “anecdotal” record of nursing behaviors and skills, and self-evaluation of one’s clinical performance.

TMCC Nursing Image

Individual instructors, prior to each clinical rotation, give specific instructions regarding preparation for scheduled clinical lab and simulation lab sessions. Unless otherwise noted, students are expected to prepare for client assignments on their own time interviewing the client and planning for care the day prior to the scheduled clinical experience. While doing clinical “prep,” students are not to do any type of “hands on” care or assessment with clients.

The clinical laboratory experience may begin with a pre-conference. During the pre-conference, general instructions may be given, and the student is assisted to plan or meet individual client needs. Student preparation for client care is also evaluated during the pre-conference.

Clinical sessions may conclude with a post-conference, during which time is usually spent sharing learning experiences. Such sharing is part of developing professional communication skills.

Invasive or Sterile Procedures

Clinical Faculty must be present during any invasive procedure, sterile procedure, or wound management procedure; the first time a student performs the procedure. Faculty will determine when a staff RN may supervise students. Students are expected to perform safely in all areas of client care. Any performance, which endangers a client's well-being, may result in the student’s removal from the clinical lab.

Any student who, in the judgment of the faculty, does not demonstrate appropriate preparation for client assignment will be:

  • Directed to the college skills lab, skills CD ROMs, hospital library or college computer lab for additional preparation and/or sent home.
  • Excluded from that clinical/laboratory session.

Students will be expected to function according to stated hospital policies relation to parking, use of cafeteria, nursing measures, uniform requirements, and routines established for the nursing unit.

Students are evaluated mid-way through each clinical rotation as well as at the conclusion of the clinical rotation. Final evaluations are completed by the clinical faculty and available to the student on the clinical tracking website.

Each clinical course has a Clinical Performance Evaluation Tool that is found on the clinical tracking website. It is the student’s responsibility to be aware of the clinical objectives and behaviors to be evaluated. Students are encouraged to schedule appointments with their instructors as needed to discuss their progress in the program. All faculty create and post a schedule office hours during which time they are available to assist students.

Unsafe Behavior/Misconduct

At the discretion of the instructor, any student who does not perform nursing interventions safely, in accordance with instruction (for example, the administration of medication) may be considered unsafe and excluded from the clinical area. A student permanently excluded from the clinical site because of unsafe nursing behavior shall fail the course, or may withdraw, in accordance with college policy.

Accident or Emergency Regulations

It is the student’s responsibility to know what the appropriate policies and regulations are regarding each clinical site for handling of accidents, emergency situations, and fire regulations during the period of rotation at each site.

Reporting of Incidents and Injury

If a student is involved in an incident with a client, a TMCC student Accident Form must be completed immediately. Incident reports must also be completed according to each agency’s policy.

If the student incurs an injury, an institution Accident Form must be filed immediately with the clinical instructor and agency. Students should be aware that some facilities require immediate drug screening.

Cellular Phones

There are no personal cellular phones, or laptop computers allowed in operation in the clinical setting at any time.

Phone Calls

Students are not to use telephones on the units to make or receive personal phone calls. If a student needs to be located regarding an emergency, contact the Health Science Office at 775- 850-4054 between 8 a.m. and 4 p.m. The Nursing administrative staff will then notify the clinical instructor who will find you. Prior to 8 a.m. and after 5 p.m., students may have the person phone or page their clinical instructor.

Electronic Equipment

Standard calculators may be used in the clinical setting only.

Clinical Assignments/Facilities

Clinical instruction is provided throughout the program in conjunction with classroom theory. This instruction is provided in various locations, such as on campus, at local hospitals, long-term care facilities, doctors’ offices and other community facilities. Because of limited clinical placements, it is not possible to assign a student specific clinical time or locations due to work assignments. Students should therefore not schedule a work assignment on a clinical day (Tuesday and/or Wednesday and some weekends). Students may be assigned to day, evening or night times for clinical rotations. Clinical assignment changes will only be made to avoid conflicts in Nursing Program degree requirements.

Clinical Dress Code

When students are in a clinical setting, they are representatives of TMCC and the Nursing Program. It is expected that the student will act and dress in a professional manner. The word “professional” can be interpreted differently by each of us. In this context, it is expected that the student will be dressed in clean, neat, tidy and conservative clothing when acting in a student capacity. Students must also comply with the dress policy for each institution.

The dress policy for students at times other than clinical experience (or classroom attendance) is as follows:

  • TMCC photo ID badge: identifying student status to be worn any time a student is functioning as a student in places other than TMCC.
    • Students must attach their ID badges to the uniform.
    • No lanyards are acceptable except those that retract.
    • No logos.
  • Clothing: clean, neat, free from stains, rips or wrinkles.
    • During pre-clinical and client selection, street clothing may be worn covered by lab coat, which is clean, unstained, and in good condition.
    • Students may wear their school uniform in place of a lab coat.
    • No tank tops, T-shirts, jeans of any color, sweat pants, shorts, leggings, spandex, stretch pants or colored underwear are allowed.
    • A clean white top may be worn under uniform top.
  • Shoes: clean and polished.
    • No sandals allowed.
    • Closed toed and heels required.
  • No chewing gum (class or clinical)
  • No chewing of tobacco products of any type (class or clinical)

All students must have with them at all clinical (or student will be sent home):

  • A working watch with a second hand. No smart watches.
  • A stethoscope.
  • Program-required current drug book(s); for example, a general and intravenous medication resource book.


  • The clinical instructor has the discretion to request conformity to specific uniform/apparel outside the listed items. These may vary from one instructor to another. This may be dependent on agency unit regulation.
  • Students not complying with the instructor’s request will be excluded from clinical until in conformance.
  • The clinical instructor’s judgment regarding appropriateness of student dress will prevail.
  • "Fanny packs" are allowed.
Category Dress Code Not Allowed
  • Hair must be worn so it does not interfere with client care (short or fastened back).
  • Long hair must be conservative in style, held away from the face in a ponytail or bun, and clean with no ribbons, decorated hair clips or scarves.
  • Hair must be neatly combed and well groomed.
  • No fluorescent or unusual colors will be allowed.
  • Beards/mustaches must be clean, short and neatly trimmed.
  • Males without full beards must be clean-shaven (no “five o’clock shadow”) when in the clinical area.
  • In the event a student has a mustache and or goatee, the remainder of facial hair should be clean-shaven.
  • A watch with a second hand is required.
  • A wedding band is allowed.
  • Jewelry may not be such that it could be a safety hazard.
  • No facial or oral jewelry permitted with the exception of one small post earring in each ear lobe.
  • No bracelets on wrists or ankles.
  • No multiple rings on multiple fingers.
  • No ear cuffs.
  • All tattoos are to be covered when in the clinical or laboratory setting.
  • Tattoos can be covered by cosmetics, adhesive bandages, or approved clothing.
  • Light make-up, if desired.
  • Basic cleanliness is expected.
  • All visible tattoos must be covered.
  • No perfume, cologne or after-shave.
  • Fingernails must be kept clean, neat and of moderate length.
  • No nail polish is to be worn.
  • No decorations.
  • No artificial fingernails.
  • Hunter green uniform shirt
  • Hunter green pants
  • White Consultation Jacket from approved vendor
  • The student uniform may not be worn while students are working for pay.
  • White leather shoes without colored decoration and with good support must be worn.
  • Shoes must be kept in good repair at all times; clean and polished,
  • Flesh colored or white-hose to be worn with dresses/pants.
  • White socks only are to be worn with pants.
  • No shoes with open back or straps and/or open toes.
Photo ID
  • A student photo ID will be required for entry to any clinical site.
  • It is the student’s responsibility to obtain the TMCC photo ID card during the scheduled opportunities.
  • Students must attach their ID badges to the uniform.
  • No lanyards are acceptable except those that retract.
  • No logos or company names.
  • Gloves will be provided only for on campus practice labs.
  • When specialized gloves are needed by the student, it is the responsibility of the student to obtain and maintain a personal supply.
Clinical Equipment
  • Required as part of the clinical uniform:
    • stethoscope
    • penlight
    • bandage scissors
    • ink pen (black)
    • safety glasses
  • These items may be purchased at any of the local uniform shops. 
  • No stethoscope covers are allowed. 


Confidentiality is both a legal and ethical concern in nursing practice. Confidentiality is the protection of private information gathered about a client during the provision of health care services. It is the nurse’s responsibility to safeguard the client’s right to privacy by protecting information of a confidential nature.

The TMCC Maxine S. Jacobs Nursing Program expects that all nursing students and faculty will protect the privacy rights, including maintaining confidentiality, of all clients.

It is expected that students and faculty will not:

  • Discuss the care of clients with anyone not involved in the client’s direct care.
  • Discuss the care of clients in any public setting.
  • Remove any actual/copied client records from the clinical setting (this includes computer printout information).
  • Use the client’s name on any written form or notation (initials only)
  • Access or attempt to access confidential patient records from another computer or computer system.

The ability to adhere to ethical and legal standards within the practice of nursing is a terminal objective for graduates of TMCC’s Maxine S. Jacobs Nursing Program. One method of assessing the student’s ability to meet this competency standard is through clinical evaluation. The performance criteria are found on the clinical evaluation tool. The student’s ability to meet these performance criteria is assessed in each clinical rotation.

Failure to maintain the client confidentiality could result in the reduction of a student’s clinical grade, a written reprimand or dismissal from the program.

With computerization of health records comes a greater risk of breaking or breaching this confidentiality. Concepts such as confidentiality (HIPPA), nurse-client or physician-client privilege are introduced at the beginning of the program, and these concepts are reinforced at mandatory orientation and by faculty in both theory and clinical courses. An orientation to HIPPA (Health Insurance Privacy and Portability Act) is given at the mandatory orientation each academic year.

Medication Administration Policy

The TMCC Nursing faculty are committed to safe medication administration and reduction of medication errors among its nursing students and graduates of the program. A strong medication administration policy along with appropriate faculty supervision is needed to oversee student medication administration. Failure to follow will result in withdrawal from the program.

Read the TMCC Nursing Program Medication Administration Policy »

Pathogen Exposure


The purpose of this procedure is to reduce the risk of student exposure to air and body substance pathogens such as, but not limited to, Tuberculosis, SARS, Hepatitis B Virus (HBV), Hepatitis C Virus (HBC), and the Human Immunodeficiency Virus (HIV).

Standard Precautions

Standard Precautions is an approach to infection control that requires the application of blood and body fluid precautions for all patients and patient specimens regardless of diagnosis. Standard precautions will be the minimum standard of practice throughout the Truckee Meadows Community College Maxine S. Jacobs Nursing Program.

Methods of Compliance

Students must become familiar and comply with the Pathogen Exposure procedure and process. Students must also become familiar and comply with the exposure plan of the clinical sites to which they are assigned.

Prevention of Exposure or Incident

Students are not to select, care for, or be assigned to clients in respiratory isolation for either TB or SARS.

Students are required to participate annually in a Blood Borne Pathogen Exposure Prevention and Control Class. The student must also have satisfactorily demonstrated skill in using protective equipment and procedures before receiving a patient care assignment.

Students must have documented immunity to hepatitis B, measles, rubella, varicella, diphtheria, prior to going to any clinical site. Students must receive annual influenza vaccinations.

Students who have received formal classroom instruction in blood borne pathogen exposure control and can satisfactorily demonstrate knowledge and skills requisite to such care are expected to accept clinical assignments in order to meet the clinical course objectives.

The decision to exempt a student from clinical experience will be made on a case-by-case basis by the faculty responsible for the clinical course.

All students must have major medical insurance upon entering and throughout their enrollment in the Nursing Program. It is the student’s responsibility to obtain and pay for this insurance, as well as to understand the benefits and limitations of any insurance policy they maintain or is maintained on their behalf.

Occurrence of Exposure or Incident

A student in the Maxine S. Jacobs Nursing Program who has exposure to blood or body fluid or other potentially infectious material to non-intact skin or mucous membranes from any source must immediately:

  • Wash needle-stick and/or cuts with soap and water.
  • Flush splashes to the nose, mouth, or skin with copious amounts of water.
  • Irrigate eyes with clean water, saline, or sterile irrigants.
  • Remove soiled personal protective equipment and/or clothing as soon as possible.

After washing, flushing and/or irrigating the exposed area, the student must immediately:

  • Notify the appropriate registered nurse at the clinical facility AND
  • Notify clinical faculty who will then implement the process below.
  • (If there is a witness to the incident, several steps can be taken simultaneously)

The Clinical Faculty will be responsible for coordinating the procedures needed to get appropriate care for the student.

The Clinical Faculty will:

  • Identify the source of the exposure.
  • Obtain stat physician’s order for needle stick exposure panel if a needle-stick.
  • Obtain consent from source client, if not in chart.
  • Determine who will be the health care provider for the student for counseling and treatment if needed.
  • Obtain phone number and name of student and the health care provider, and provide this information to the contacts listed below.
  • Normally the labs will be run STAT and reported to the contacts as listed.
  • Provide the student with contact information to obtain source testing results (normally Employee Health).
  • Send the student to their health care provider to obtain medical evaluation and post-exposure follow-up within 1 to 2 hours of the exposure (except as noted below for the VAMC).
  • Medical evaluation may be at the healthcare facility of the clinical agency; with a private healthcare provider; at an urgent care facility; or at an emergency room.
  • Student should bring a copy of the documents with as much completed information as possible to the health care provider. They should also have the contact number for source information (normally the Employee Health Office) so that the health care provider may obtain results.
  • Initiate the documentation needed for TMCC, and the clinical agency.

Clinical Agencies

  • Carson Tahoe Regional Medical Center
    • 775-445-8000
  • Northern Nevada Medical Center
    • Notify the Emergency Department at 775-356-4040. After hours notify the House Supervisor.
  • Saint Mary’s Regional Medical Center
    • Notify Employee Health at 775-770-3525. After hours call the House Supervisor.
    • Medications are available if needed for a one day period of time.
  • Veteran’s Administration Medical Center
    • Notify Infection Prevention at 775-786-7200, extension 1374.
    • NOTE: The VAMC will evaluate the student at Employee Health and provide counseling and any needed treatment.
  • Renown Regional Health System
    • Notify Employee Health at Renown Regional Medical Center.
    • After hours call the Health Hotline at 775-982-5757 select Option 1 to speak to the nurse.
    • If treatment is needed, medications are available through the House Supervisor for a maximum 3 day supply.

Note: The National HIV/AIDS Center provides a PEPline, a Clinicians’ Post-Exposure Prophylaxis Hotline which offers up-to the minute advice on managing occupational exposures (needlesticks, etc.) to HIV, hepatitis and other blood borne pathogens. It is offered 24 hours a day, 7 days a week at 1-888-448-4911.

There is also a Clinician’s Consultation Center that is free of charge. This Warmline is staffed by physicians, clinical pharmacists and nurse practitioners Monday through Friday from 5 a.m. to 5 p.m. Pacific Time at 1-800-933-3413.

Documentation and Follow-up

Student and faculty:

  • Complete an incident report at the clinical facility, and be aware of and follow any reporting and follow-up requirements of the clinical facility.
  • Complete a TMCC Injury Report.
  • Notify the Director of Nursing of the incident as quickly as possible.
  • It is the student’s responsibility to make his/her healthcare provider aware of the results of any blood panel drawn as a result of an exposure.
  • It is the student’s responsibility to follow-up with any counseling recommended by his/her healthcare provider as a result of an exposure.
  • It is the student’s responsibility to follow-up with any treatment recommended by his/her healthcare provider as a result of an exposure.
  • The student has financial responsibility for any cost associated with evaluation, treatment and/or counseling that results from an exposure.
  • The clinical facility will collect as much information as possible from the source patient following an exposure.
  • While the College will make every effort to maintain confidentiality, the College cannot be held responsible for acts and omissions of the clinical agency.

Patient Safety

Background: Patient safety is the minimizing of risk of harm to patients and providers through both system effectiveness and individual performance.

Nursing: Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2004).

Critical Thinking: According to Ebright et al. (2005), as cited in Cronenwet et al. (2007) several factors related to safety influence a nurse’s ability to make logical and accurate decisions:

  • Knowledge base
  • Attention
  • Barriers to care (like workplace obstacles)
  • Number of tasks
  • Missing essential information
  • Behaviors not encouraging of productive thought

Nursing Process: The nursing process is the basis of all clinical judgments and includes all dealings made by nurses in providing care to patients. Considerations for culture, safety, education, health and wellness, patient care, self-health promotion, and planning for long-term health maintenance are included in nursing measures. (Potter et al, 2005 as cited in Cronenwet et al. 2007). Nurses perform clinical decision-making using the nursing process as a framework. Overall, it is a problem-solving activity focusing on recognizing and defining patient issues and selecting appropriate interventions (Ebright et al., 2005) as cited in Cronenwet et al. (2007).

Complexity of Nurse Work: Due to the increasingly complex nature of the role of nurses and increasing patient acuity, everyday nursing duties are also a challenge in protecting the safety of every patient. Ebright et al, (2005), as cited in Cronenwet et al. (2007) found the following factors related to safety of delivering patient care:

  • Variety of supply locations
  • Locating supplies when not found in designated areas or not adequately stocked
  • Repetitive travel (to patient’s rooms, nurse’s stations, supply locations, etc.)
  • Unexpected situations, interruptions and distractions
  • Pauses to wait for system services (computers or medication carts)
  • Inadequate resource access for further care and new procedures
  • Miscommunication
  • Errors due to handwriting and labeling

Student nurses are expected to be able to delineate general categories of errors and hazards in care and communicate observations or concerns related to hazards and errors to patients, families and the health care team Students develop patient assessment skills which are taught throughout the program and gain increasing skill in determining variations from normal that affect patient safety. Some areas are very significant in ensuring patient safety in a hospital setting: mobility, level of awareness, critical condition and mental state:

Students and all healthcare providers should wash their hands or use a hand sanitizer before and after each patient interaction. Students comply with medication administration policies and procedures which stress safe medication administration, focusing on the following “rights:”

Knowledge Skills and Attitudes that Emphasize the Importance of Standardization and Safety Enhancing Technologies

Knowledge Skills Attitudes
Examine human factors and other basic safety design principles as well as commonly used unsafe practices (i.e., workarounds and dangerous abbreviations) Demonstrate effective use of technology and standardized practices that support safety and quality such as sterile procedures and pressure ulcer prevention. Value the contributions of standardization and reliability to safety
Describe the benefits and limitations of selected safety - enhancing technologies (such as, barcodes, Computer Provider Order Entry, medication pumps and automatic alerts/alarms). Use appropriate strategies to reduce reliance on memory such as systematic
organizational tools and checklists).
Appreciate the cognitive and physical limits of human performance.
Discuss effective strategies to reduce reliance on memory.    

Investigating Incidents

The Maxine S. Jacobs Nursing Program and health care facilities have a process for investigating incidents. The following knowledge, skills and attitudes are reinforced by the faculty:

Knowledge Skills Attitudes
Describe factors that create a culture of safety (such as, open communication strategies and organizational error reporting systems). Use organizational error reporting systems for near miss and error reporting. Value own role in preventing errors.
Describe processes used in understanding causes of error and allocation of responsibility and accountability (such as, root cause analysis and failure mode effects analysis). Participate appropriately in analyzing errors and designing system improvements. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team.
  Engage in root cause analysis rather than blaming when errors or near misses occur.   
Discuss potential and actual impact of national patient safety resources, initiatives and regulations Use National Patient Safety resources for own professional development and to focus attention on safety in car settings. Value relationship between current National Safety Campaigns and implementation in local practices and practice settings.

Reporting Sentinel Events to the Nevada State Board of Nursing (NSBN)

All Sentinel Events affecting patient safety are reported to the Nevada State Board of Nursing. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome (2007, The Joint Commission).

Unsafe or Unsatisfactory Work

The instructor will assess and evaluate patterns and/or unsafe behaviors to determine degree of risk to the client. The student will be informed of instances of unsafe behavior. The following may be grounds for dismissal from the Maxine S. Jacobs Nursing Program:

  • Unacceptable clinical behavior
    • Immediate dismissal from the Nursing Program may occur at any time when client’s safety is in jeopardy. The student may also be informed of unsafe clinical behavior first by a verbal warning then a written warning and dismissal from the program may follow.
  • Excessive absences or tardiness
    • Tardiness and/or absences can seriously interfere with a student’s learning process. At the point when absences/tardiness becomes a concern, endangering a student’s progress, a contractual agreement will be established between student and faculty, outlining specific behavior expected in order for the student to complete the course.
  • Inability to successfully complete courses
    • If a student is unable to successfully complete a course for any of the following reasons, they may be dropped or be given a failing grade depending upon:
      • The amount of content/clinical lab experience missed.
      • Inability to proceed due to lack of successfully completing a prerequisite in the sequence listed.
  • Inability to adjust to stress adequately to perform duties safely with clients
  • Inability to apply the necessary knowledge to perform the following duties with clients
    • Identify the client (identiband or in the absence of an identiband, the procedure as established within specific units, i.e., psych, critical care, burn, labor and delivery, peds,) properly.
    • Provide care within acceptable standards of care for students.
  • Inability to accept responsibility for consequences of one’s own behavior
    • Validate with instructor rationale for action when contrary to classroom instruction.
    • Decline assignments made by staff when that assignment is inconsistent with objectives or expectations for level of student.
    • Adhere to policies regarding scheduled medications, i.e., never possess narcotics key without supervision nor access electronic medication delivery system (PIXIS, DIEBOLD) without supervision.
  • Inability to demonstrate responsibility for client care by notifying the instructor and clinical faculty in the event of an absence or tardiness
  • Inability to demonstrate acceptable working relationships
    • Answers call lights.
    • Relate appropriately with others (client, families, instructors, staff, peers, etc.)
  • Inability to demonstrate fairness and straight forwardness in conduct
    • Free from fraud or deception
    • Maintain client confidentiality.
    • Report errors and unsafe conditions.
  • Inability to consistently receive, interpret, and carry out instructions

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