Creating Clinical/Simulated Learning Experiences

Teaching in the Clinical Setting*

Paula Gubrud, EdD, RN, FAAN

The health care system is ever changing and the Patient Protection and Affordable Care Act (PPACA) (Patient Protection and Affordable Care Act, 2014) challenges faculty to prepare students for future roles and to practice in a health care system that is patient-centered, wellness-oriented, community- and population-based, and technologically advanced. Clinical settings within a variety of health care systems have also become highly complex. Clinical learning occurs in actual health care environments and laboratory settings where students apply their acquired knowledge and skills as they think critically, make clinical decisions, and acquire professional values necessary to work in the practice environment. The purpose of this chapter is to describe the environments for clinical teaching and learning, how the curriculum relates to clinical teaching, roles and responsibilities of clinical teachers, and teaching methods and models that facilitate learning in clinical environments.

Practice Learning Environments

The environment for practicum experiences may be any place where students interact with patients and families for purposes such as acquiring needed cognitive skills that facilitate clinical reasoning and decision-making as well as psychomotor and affective skills. The practicum environment, also referred to as the clinical learning environment (CLE), is an interactive network of forces within the clinical setting that influence students’ clinical learning outcomes. The environment also provides opportunities for students to integrate theoretical nursing knowledge into nursing care, cultivate clinical reasoning and judgment skills, and develop a professional identity (O’Mara, McDonald, Gillespie, Brown, & Miles, 2014). The CLE introduces students to the expectations of the practice environment, as well as the roles and responsibilities of health care professionals. To accomplish these outcomes, a variety of experiences are required in multiple settings. These settings may be special venues within schools of nursing or within acute care settings or communities. It is essential that practice environments be supportive and conducive to learning so that students will develop the qualities and skill abilities needed to become competent professionals (O’Mara et al., 2014). The following section describes these settings. Included among these are practice learning centers such as learning labs, acute and transitional care, and community-based environments.

Clinical Learning Resource Centers

To foster a nonthreatening and safe learning environment, the practice learning center is used at several stages of students’ learning. These centers encourage guided experiences that allow students to practice and perfect a variety of psychomotor, affective, and cognitive skills such as critical thinking and clinical reasoning before moving into complex patient environments. Simulation is one example of a teaching method used in the practice learning center. This method is increasingly used to evaluate knowledge acquisition as well as skill sets (Jeffries, 2014).

Simulation

According to the National Council of State Boards of Nursing (NCSBN, 2005), “simulation is a teaching strategy used to validate the complex and comprehensive skill required of health care professionals.” 283Simulation-based learning is designed to replicate the reality of the clinical environment to provide participants with opportunities to practice and refine clinical reasoning, skilled procedures, and interprofessional collaboration. Schiavenato (2009) also states, “The human patient simulator (HPS) or high-fidelity mannequin has become synonymous with the word simulation in nursing education” (p. 388). The explosion of simulation as a standard clinical learning activity is evident in the literature and a recent multisite study validates the use of this modality in clinical education (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). This study included 10 prelicensure sites and used a three-group quasiexperimental research design. The control group had traditional clinical experiences with no more than 10% of their time spent in simulation. One experimental group had 25% of their clinical time in simulation, and the other experimental group spent 50% of their clinical time in simulation. The study began with the first clinical courses and used multiple measures to assess participants’ nursing knowledge and clinical competency throughout the entire program of study. Study participants also rated how their learning needs were met in both simulation and in the clinical environment. Study results found no significant differences between all groups among assessment measures. The study validates simulation as high-quality clinical learning experience that can be used to replace a significant number of traditional clinical hours.

Virtual Clinical Practica

Given the challenges of finding sufficient clinical experiences for students, faculty are exploring the use of virtual clinical experiences made possible by online technologies that can create virtual clinical environments (Knapfel, Moore, & Skiba, 2014) and use existing technologies such as electronic intensive care units and telehealth capabilities to create opportunities for clinical experiences focused on providing opportunities to practice critical thinking, clinical reasoning, communication, and teamwork as a member of the interprofessional team (Sepples, Goran, & Zimmer-Rankin, 2013). The virtual clinical practicum (VCP) is designed to provide a live clinical experience to nursing students from a distance. Students gain clinical experience and practice skills and clinical judgment using telehealth technologies in which students observe a nurse taking care of a patient in a clinical setting without going to the actual clinical site, or as a registered nurse in masters doctoral programs who are learning to provide the care. The students can interact with the nurse, other members of the interprofessional team, and the patient using telehealth technology. The VCP process is developing as a potential solution in response to limited clinical practice sites as well as limited clinical experts, and for specific populations such as acute care pediatric patients. VCP provides needed clinical learning opportunity, especially in rural areas. (See Chapter 21 for further discussion of virtual environments.)

Acute and Transitional Care Environments

Acute and transitional care environments provide clinical experiences for undergraduate and graduate students preparing for advanced practice roles. Experiences in these environments enable undergraduate students, in particular, to exemplify caring abilities and practice the use of cognitive, psychomotor, and communication skills as they interact with patients and their families. These environments have become increasingly complex. A recent multisite study found that the complexity relates to factors such as extensive use of technology (e.g., electronic health records), rapid patient and staff turnover, high patient acuity, and complex patient needs (McNelis et al., 2014). These sites are suitable for learning experiences that focus on providing care in complex clinical settings, but faculty must consider the level of the student, the focus of the experience and the increased risk to patient safety when students have clinical assignments in these units.

Clinical Cases, Unfolding Case Studies, Scenarios, and Simulations

Simulated experiences that provide opportunities for students to integrate psychomotor, critical thinking, and clinical reasoning decision-making skills are equally valuable in assisting students to critically evaluate their own actions and reflect on their own abilities to apply theory to practice. The use of the high-fidelity HPS is one example of using realistic scenarios to prepare students for clinical experiences, substitute for unavailable or unpredictable clinical experiences, or enhance clinical experiences in a safe environment. The use of HPS helps transition the student from the classroom to the practicum environment. Students’ learning with the HPS method can be enhanced, patient care can 284be optimized, and patient safety can be improved. Additional benefits may include enhanced learning in a risk-free environment, promotion of interactive learning, repeated practice of skills, and immediate faculty or tutor feedback. (See Chapter 18 for additional discussion.) Cases, unfolding case studies, and scenarios are lower fidelity strategies but are equally helpful in preparing students for clinical experiences and bridging the gap between classroom and practice (Benner, Sutphen, Leonard, & Day, 2010; McNelis et al., 2014).

Community-Based Environments

The health care delivery system and implementation of the PPACA is continuing to shift nursing practice from acute care hospital environments to the outpatient and community settings. These changes have resulted in care provided through the medical home model (Henderson, Princell, & Martin, 2012) and an increased use of community agencies such as ambulatory, long-term, home health, and nurse-managed clinics; hospice; homeless shelters; social agencies (e.g., homes for battered women); physicians’ offices; health maintenance organizations; and worksite venues and summer camps.

The use of technology such as video conferencing, wireless remote communication, information systems, and online courses has made it possible for clinical experiences in a community-based environment to occur at a distance. The transition to community-based teaching requires the faculty to ensure that learning opportunities available in the clinical placement allow the student to achieve the learning objectives. Faculty must adapt clinical learning experiences and incorporate skills used to develop competency with new technology and modify teaching methods (Bisholt, Ohlsson, Kullén Engström, Sundler Johansson, & Gustafsson, 2014). Additionally faculty must adapt to methods of clinical supervision such as being accessible by mobile phone and texting.

Establishing appropriate and sufficient learning experiences in the community may be difficult and challenging. These challenges often relate to economic constraints and the changes in nurse staffing patterns, with a resultant lack of time for professionals to facilitate skill development and serve as role models. These challenges may require faculty to be creative in their use and selection of resources within these environments and to consider establishing partnerships with the service agencies. Using community-based settings creates opportunity for critical thinking, understanding the health care system, and development of communication skills. Faculty can provide other experiences using simulation or the clinical learning laboratory to assist students to develop proficiency in skills traditionally performed in the acute care setting.

Learner-Centered Clinical Education Environment

Every health care environment and specific unit within these environments has a culture. The culture of the immediate environment affects teaching and learning (O’Mara et al., 2014). For example, the culture or patterns of actions and behaviors of the health care professionals can be observed in their attitudes, interactions, teamwork, and commitment to quality and safe patient care. Staffing levels, acuity of patients, anxiety of staff, and workload can influence these actions and behaviors. These aspects of the culture of the environment can in turn influence the time staff has to devote to students. The culture of the environment may also result in behaviors related to lateral violence. Lateral violence is often observed, witnessed, and verbalized by students. These verbalizations provide an opportunity for faculty to implement strategies and assist students with processing what they may be seeing, hearing, and feeling, and thus lessen the effects of these behaviors on students’ learning. For example, faculty can hold debriefing sessions, listen to students’ perceptions, and make concerted efforts to balance students’ feelings and thoughts by using appropriate strategies to soften, yet not deny, the reality of the culture.

Selecting Health Care Environments

Regardless of the practice environment, faculty are responsible for selecting appropriate CLEs within health care agencies and other organizations such as schools and social service agencies. Faculty must be aware of what particular systems are in place within the program to negotiate contracts that are congruent with the philosophies of the school of nursing and the agency, as well as those that specify the rights and responsibilities of both. Determinations must be made about regulation and accreditation status, adequacy of staff, the patient population for needed experiences, expected course outcomes, and whether or not the practice model is compatible for intended uses and curriculum needs. In addition, the 285adequacy and availability of physical resources (e.g., conference space) for students and faculty should be determined. Finding a practice environment that meets all specified needs is becoming a challenge because of factors associated with the delivery of health care. For example, rapid patient turnover often means faculty have to select available patients rather than those that best meet students’ learning needs. This limitation in patient availability can create opportunities for faculty to be creative in the manner in which learning experiences are selected and teaching strategies used. Regardless of the limitation, the role of the faculty is to assist students in making learning connections focused on application of content presented in the classroom to clinical practice. Dual clinical and classroom assignments for faculty may assist in making those necessary connections between clinical and classroom. “The very strength of pedagogical approaches in the clinical setting is itself a persuasive argument for intentional integration of knowledge, clinical reasoning, and skilled know-how and ethical comportment across the nursing curriculum” (Benner et al., 2010, p. 159). Thus faculty have a significant role in helping students to make the necessary connections between clinical and classroom experiences as they learn to think and act like a nurse (Tanner, 2002), in spite of limitations for clinical learning in the health care environment.

Building Relationships with Personnel within Health Care Agency Environments

The ability of the clinical faculty to facilitate students’ learning can be enhanced when an effective working relationship is established within the clinical agency. Effective relationships begin with effective communication, which must be practiced in an ongoing manner to maintain relationships and facilitate learning (Dahlke, Baumbusch, Affleck, & Kwon, 2012). This requires having an understanding of the environment and the roles of the individuals within the environment, adapting teaching approaches to the situation, and establishing relationships aimed toward enhancing the educational experience. These elements do not exist in isolation but are patterned to dovetail with or complement other roles. Information should be shared continually, clearly, and consistently about goals, competencies, and expected outcomes; the level of students; practice expectations; the clinical schedule; and related information. Such information enables staff to assist with identification of appropriate experiences for students.

Inasmuch as clinical faculty have the primary responsibility for teaching and guiding students in the clinical environment, others often assist in the process. Therefore the sharing of expectations with the staff is critical. Ensuring an orientation to the practicum environment and having students engage with staff early in the clinical experience promote positive student–staff interaction and provide opportunities for role clarification and the development of collegial relationships. A consistent demonstration of awareness of the mission and values of the agency through actions that are inherently respectful is crucial. Follow-up communication provides an avenue for those within the practice environment to keep abreast of changes.

Clinical Practicum Experiences across the Curriculum

Understanding the Curriculum

The curriculum, composed of a series of well-organized and logical entities, guides the selection of learning experiences and clinical assignments, organizes teaching–learning activities, and informs the measurement of student performance. The manner in which the curriculum is organized guides the planning of learning experiences in a logical, rational sequence. The curriculum is designed to build on prior knowledge and to reinforce the application of learning. While this description of curriculum relates to process, this does not preclude faculty’s use of creative and innovative methods in clinical environments. Creative methods have a high potential to motivate students and facilitate construction of knowledge to be applied in practice. Studies focused on perceptions of both clinical instructors and students indicate understanding the whole curriculum is a critical aspect of clinical instruction (Bisholt et al., 2014; Dahlke et al., 2012; Wyte-Lake, Tran, Bowman, Needlemann, & Dobablian, 2013). As students progress and engage in varied practicum experiences, it is faculty’s responsibility to interpret the curriculum and to describe the relationships between course competencies and practicum experiences.

Understanding the Student

Clinical experiences provide opportunities for students to practice the art and science of nursing, which enhances their ability to learn. To maximize these 286experiences, faculty must have full knowledge and understanding of each student (see also Chapter 2). The nursing student population is culturally diverse and includes members of varied age groups, many ethnic and racial groups, and an increasing number of men. This population is also likely to include persons with (or without) prior degrees from a variety of disciplines, as well as those who possess many different health care experiences and technological skill levels. In addition, students differ in their learning styles, levels of knowledge, and preferences for learning experiences; therefore faculty must make concerted efforts to balance the students’ learning needs, interests, and abilities when selecting clinical experiences without losing sight of the curriculum and expected competencies and outcomes. Such action can be facilitated by making an assessment of the knowledge, culture, and skills of the learner. Such an assessment helps the faculty determine whether students possess the cognitive, critical thinking, clinical reasoning, decision-making, psychomotor, and affective skills needed for the experiences.

Understanding the Clinical Environment

The clinical environment has been described as a place where students synthesize the knowledge gained in the classroom and make applications to practical situations. Chan (2002) describes the CLE as “the interaction network of forces within the clinical setting that influences student learning outcomes” (p. 70). A number of forces affect expected learning outcomes, including the availability of staff for supervision and coaching, and the degree of student-centeredness exhibited by the clinical teachers (Chan, 2002; Newton, Jolly, Ockerby, & Cross, 2012). Additionally, opportunities available for students to pursue individual learning outcomes define the effectiveness of the clinical environment (Newton et al., 2012). The extent to which the clinical environment values nurses’ work and provides an adaptive culture that embraces innovation, creativity, and flexible work practices also are important aspects that set the stage of effective learning (Newton et al., 2012). These forces, coupled with the need to adjust to an environment that requires an integration of thinking skills and performance skills, often result in increased anxiety among students. Creating a supportive clinical environment involves comprehensive orientation of students to the environment, ensuring they are prepared to perform necessary skills and encouraging creative and critical thinking (Ganley & Linnard-Palmer, 2010). Creating an environment where students are expected to succeed also reduces student anxiety (Ganley & Linnard-Palmer, 2010).

Traditionally, clinical rotations have consisted of short blocks of time spent on a unit caring for a patient or two, mostly performing nursing skills with little or no time dedicated to focus on integration of theory, application of critical thinking, and clinical reasoning. Often there is minimal focus on providing feedback or effective evaluation of the interventions performed. Additionally, the focus of the CLE is often focused on the operational aspects of the unit. Nursing staff are expected to meet productivity goals and are caring for patients that are extremely ill with multiple health care needs in complex and dynamic organizations. Nurses intuitively want to be good role models and nurture students but often do not have the time to do so. Faculty must balance the operational needs of the unit with the importance of ensuring that students receive feedback and have the opportunity to focus on daily learning goals related to clinical course outcomes.

Regardless of location of the practice setting, faculty and staff should provide an environment in which caring relationships are evident. The clinical practice environment should be a place where students feel that they are accepted and their contributions are appreciated by individuals with whom they interact (Chan, 2002). Attributes of staff such as warmth, support in obtaining access to learning experiences, and willingness to engage in a teaching relationship are considered helpful.

Selecting Clinical Practicum Experiences

Practicum experiences refer to all activities in which students engage in the practice of nursing. Such experiences are essential for knowledge application, skill development, and professional socialization. Practicum experiences are selected and planned to provide students with opportunities to work across settings and manage care for varied populations with emphasis on applying theory content from the classroom to the clinical experiences. Clinical experiences should include an emphasis on the nursing roles related to health promotion and disease prevention. Selection of practicum learning experiences requires all faculty to be knowledgeable about clinical education and have a sound understanding of the curriculum, the learners, and the learning environment.

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The practicum experiences should also help students prepare for outcomes in a progressive, developmental manner. Experiences with patients from diverse populations and with different levels of wellness should be provided. Faculty should take advantage of opportunities to use their creative talents, clinical skills, and expertise to ensure that all students have opportunities to interface virtually or directly with a variety of patient populations.

As faculty begin to plan the clinical experience, it is essential to determine the goal of the particular clinical experience for that day. For the beginning student, focused clinical experiences in which the student is to focus on specific objectives and to achieve specific competencies incorporating individual learning needs requires faculty to create focused, goal-oriented learning activities (Gubrud-Howe & Schoessler, 2009). In a focused clinical learning activity, instead of providing all required care for one or two patients, students can focus on becoming proficient at a particular skill by practicing that skill for several patients. For example, students may interview several patients to work on communication skills, perform vital sign assessments on multiple patients to develop this particular skill set, or focus on learning standards of care in a specialty area. Organizing learning experiences allowing students to assign and delegate care or give and receive reports are other examples of focused clinical learning activities. The purpose of focused clinical learning is to design clinical learning experiences focusing on repetitive practice related to a particular skill set. Focused experienced should integrate students’ individual learning needs and focus on course outcomes.

Other learning goals may emphasize facilitating students’ ability to synthesize information, integrate didactic and clinical knowledge, develop clinical reasoning and judgment skills, and plan care for groups of patients (Benner et al., 2010; Tanner, 2010). Here, assignments that involve planning care for patients with complex needs and for multiple patients are appropriate. These integrative clinical experiences prepare students for transition to practice and typically occur toward the end of the program.

The selection of experiences should be consistent with the desired course and curriculum outcomes, which may be multiple and specific to the nursing program. For example, the expected outcomes for students in an undergraduate degree nursing program are different than those for students in a graduate degree program. Therefore the learning experiences and clinical environment that are selected and the practice opportunities that are offered to students should be congruent with the program outcomes.

Interprofessional Clinical Education

Learning to collaborate with the many health care groups involved in patient care can be a daunting task. Through these experiences, nursing students can learn to work collaboratively with a variety of health disciplines. Therefore students should be provided with opportunities to work as members of interprofessional teams and in practice environments where practice models are used for joint planning, implementation, and evaluation of outcomes of care. The goal of interprofessional education is to foster development of teamwork competencies while enhancing contribution to each profession.

Interprofessional simulations may assist students in health care disciplines such as nursing, medicine, pharmacy, and respiratory therapy to learn about the clinical management of a variety of patients. Several recent studies demonstrate interprofessional simulations may improve patient care through shared learning, development of collaborative team functioning, and shared knowledge creation leading to trust and thoughtful decision making (Bandali, Craig, & Ziv, 2012; Reese, Jeffries, & Engum, 2010; Smithburger, Kane-Gill, Kloet, Lohr, & Seybert, 2013; Strouse, 2010).

Nursing faculty are increasingly participating in teams and designing interprofessional clinical courses and learning experiences. Successful course development and implementation depend on faculty’s commitment to the goal of interprofessional practice and a wide range of additional factors. For example, educators must demonstrate professional respect and role clarity. Educators must also have the ability to secure clinical facilities and develop schedules for clinical experiences that are compatible with the concurrent coursework and curriculum progression in each discipline. Other factors include identification of content and experiences with similarities, differences, and overlaps, as well as clarification of autonomy and role interdependency. Success depends on the ability to identify philosophical similarities and differences in clinical practice and to establish clear communication through avenues such as frequent interdisciplinary clinical conferences.

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An expected outcome of interprofessional education is increased future collaboration among professionals (Interprofessional Education Collaborative Expert Panel, 2011). The assumption is that students who are taught together will learn to collaborate more effectively when they later assume professional roles in an integrated health care system. Rewards and benefits of interprofessional practice and education include clearer understanding of roles and better employment opportunities for graduates. The long-term outcome is improved access to care, quality care, and increased patient satisfaction and safety. (See also Chapter 11.)

Evaluating Experiences

Students are required to demonstrate multiple behaviors in cognitive, psychomotor, and affective domains. Consequently, clinical faculty must evaluate students in each of these areas. The evaluation must be both ongoing (formative evaluation) to assist students in learning and terminal (summative evaluation) to determine learning outcomes. Constructive and timely feedback, which promotes achievement and growth, is an essential element of evaluation. For a discussion of clinical performance evaluation, refer to Chapter 25.

Scheduling Clinical Practicum Assignments

Although faculty schedule clinical practicum experiences to promote learning, there is ongoing dialogue about the best way to schedule experiences, with emphasis placed on the length of the experiences (hours per day, number of days per week, number of weeks per semester), the timing of the experiences in relation to didactic course assignments, and student needs. Faculty should consider course goals related to both theory and clinical courses and integration of theory content with clinical experiences when making scheduling decisions.

When the learning goal is to integrate students into a clinical setting or when the students are working with a preceptor, students may work the same shift as the nurse with whom they are paired. Many acute care hospitals have a 8-hour shift option, whereas others have only 12-hour shifts. Giving students the opportunity to work the 12-hour shift affords the full scope of practice in any given nurse’s day. Students are able to quickly see and experience the role of the nurse. In one small study of senior nursing students in a second degree program working a 12-hour shift, Rossen and Fegan (2009) found that benefits included that students felt accepted by staff, had better socialization, and experienced a realistic work environment; disadvantages included decreased teaching time from the faculty. Although a shorter clinical day allows for skill acquisition, there is little time for the development of extensive critical thinking, clinical reasoning, and evaluation of care. It is equally important that students be exposed to the unit’s structure, operations, and culture.

Although results of research about outcomes and student satisfaction with timing and scheduling of clinical experiences offer some guidance, faculty also must consider additional variables such as availability of patients, clinical facilities, course schedules, and student needs. Scheduling is frequently influenced by the desire to have concurrent classroom and clinical experiences so that knowledge can be transferred and applied immediately. Clinical scheduling can be further complicated by the need to coordinate schedules of students from more than one school of nursing. Thus, ideal scheduling may not be a reality.

Effective Clinical Teaching

Clinical teaching must use multiple instructional techniques and teaching tactics to develop and adapt to the environment in which students have opportunities. The clinical instructor should implement activities aimed to foster mutual respect and support for students with each other while they are achieving identified learning outcomes. Faculty who teach in practicum environments are the crucial links to successful experiences for students.

Research about clinical teaching over time consistently indicates that effective clinical teachers are clinically competent, communicate clear expectations, are approachable, and can coach students through difficult patient situations (Dahlke et al., 2012). Additionally, students indicate effective clinical teachers have knowledge of the clinical environment and curriculum, make clinical learning enjoyable through supportive actions, express empathy, and communicate passion for the profession). Making clinical learning enjoyable involves helping students connect theory to practice and applying clinical reasoning while using a patient-centered approach to addressing problems (Dahlke et al., 2012).

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Being knowledgeable and being able to share practice wisdom with students in clinical settings is essential. Such knowledge includes an understanding of the theories and concepts related to the practice of nursing. Equally important is an ability to convey the knowledge in an understandable manner. Karuhije (1997) directs attention to three discrete teaching domains that will facilitate acquisition of the teaching skills needed to foster success in clinical settings: instructional, interpersonal, and evaluative. Instructional refers to approaches or strategies used to facilitate a transfer of knowledge from didactic to practicum. Strategies may include questioning and peer or patient teaching. Faculty should be cognizant that the type of questions can cover a range during exchanges with students. Faculty should also be mindful of the manner in which questions are constructed to facilitate positive effects on learning. Questions that ask students to analyze and synthesize information, to make clinical judgments, to evaluate outcomes of care, or to propose alternative courses of action result in more learning than simple recall. In clinical practice, factors such as the nature of the situation and available time are likely to influence the types of questions raised.

Effective clinical teaching requires educators to coach students as they learn clinical reasoning and judgment. Clinical reasoning is a “complex process that uses cognition, metacognition, and discipline-specific knowledge to gather and analyze patient information, evaluate its significance, and weigh alternative actions” (Simmons, 2010, p. 1151). Clinical judgment is the outcome of the clinical reasoning process and is defined as “an interpretation or conclusion about a patient’s needs, concerns or health problems and/or the decision to take action (or not), and to use or modify standard approaches, or to improvise new ones as deemed appropriate by the patient’s response” (Tanner, 2006, p. 204). Clinical reasoning occurs when an individual has the ability to reason about the details of a particular clinical situation and identify what is salient (Benner et al., 2010; Tanner, 2006). Effective and efficient clinical reasoning is derived from knowing the patient, grasping baseline data, and understanding the case (Gillespie & Patterson, 2009). Clinical reasoning requires knowledge, skills, and abilities grounded in reflection. Clinical reasoning is supported by an individual’s capacity for self-regulation and leads to the development of expertise (Kuiper, Pesut, & Kautz, 2009).

Beginning students struggle with the ability to engage in clinical reasoning required to make sound judgments. The novice student does not have the ability to identify the subtle or relevant cues seen in a patient whose health condition is changing and for whom complications are beginning to occur. Faculty can assist students in identifying these subtle and relevant cues and start to collaborate with other health care professionals to provide the interventions needed to anticipate potential problems and consider the options aimed toward eliminating or treating complications (Cappelletti, Engel, & Prentice, 2014). (See Box 17-1).

Box 17-1

Clinical ReasoningSubtle Changes and ComplicationsRelevant “Cues”Anticipated Collaborative InterventionsAnticipated OutcomesPulmonary edema

• Breath sounds (crackles, wheezing)

• Semi- or high Fowler’s position

• Decreased shortness of breath

• Coughing

• Implement call orders related to low O2

• Increase FiO2 and PaO2

• FiO2 % decreased

• PaO2 decreased

• Using SBAR, contact physician to obtain orders

• Normotensive

• Increased U/O

• Shortness of breath

• Anticipate the following:

• No accessory muscle use

• Cyanosis

• Diuretic: (e.g., Lasix)

• Clear breath sounds

• Tachypnea

• Orthopnea

• Chest X-ray

• Decrease IV fluids

• No arrhythmias associated with low K +

• Anxiety

• Give K + if low

• Accessory muscle use

• Blood-tinged sputum

• Hypertension or hypotension

Coaching and Giving Feedback

Coaching students to help them develop clinical competency requires giving students feedback. Feedback, an essential element in teaching and learning, is described as information communicated to students as a result of an assessment of an action by students (Wells & McLaughlin, 2014). Feedback, when properly delivered, has a high potential for learning and achievement. In clinical practice where assessments need to be made about the extent to which clinical competencies are met, clinical faculty have a variety of opportunities to offer feedback in response to performance behaviors relating to psychomotor as well as cognitive and affective actions. Regardless of the action, key considerations should be practiced. These considerations are specificity, timing, consistency, continuity, and approach. Approach is important because of its capacity to alleviate anxiety and enhance engagement.

Because of the variations in needs of students, each clinical experience provides opportunities for feedback. It is imperative that feedback not be given only at documented, scheduled times for formative and summative evaluations. Faculty should be cognizant of those actions that require immediate interaction and those for which feedback can be delayed until a short time later, but not too much later. Methods must be identified to maintain data for timely sharing both strengths and challenges with students, for example. Faculty should create an efficient system for making brief written or electronic anecdotal or mental notes. The delivery of feedback can take multiple forms and depends on the situation. Face-to-face, time-sensitive, brief conferences (e.g., a few minutes) or electronic conversations or dialogue are examples.

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Regardless of the method of delivery, guiding principles must be applied and the learning intent of feedback should be provided. Knowing how to give feedback regarding clinical performance and written clinical assignments is an important element of teaching. One method is to point out positive aspects of performance as well as areas that require improvement. Some situations may provide an opportune time to role-model. For example, if a student fails to integrate communication while performing a procedure, faculty can fill in the missing words. Such action may (or may not) alert the student to an “aha” learning moment: “I failed to communicate. . . .” The faculty interjecting could have a lasting outcome. See Chapter 25 for information about assessing clinical learning and the delivery of feedback.

Debriefing and guided reflections are forms of feedback often used immediately following a clinical experience, nursing rounds, simulation, or presentation to determine the extent to which expectations were met and identify any areas of concern (Overstreet, 2010). In the process of making determinations, the discussion often evolves into identifying areas needing improvement. Although debriefing sessions generally take place in group settings (e.g., in clinical conferences), it is not uncommon for sessions to occur on a one-on-one basis. Faculty may take the lead by posing specific questions and listening to responses to guide further discussion. Students assume an active role in debriefing sessions and can take the lead in initiating the process (Dreifuerst, 2012).

Effective clinical teachers are expected to have expertise in the “art” of teaching. Equally important are teacher behaviors that facilitate learning and support students in their acquisition of nursing skills. Empirical evidence correlates specific teaching methods with enhanced student learning. A recent study suggests effective clinical teaching involves the ability to optimize the environment to provide meaningful learning experiences focused on predetermined objectives (Gubrud-Howe & Schoessler, 2009). Facilitation of cooperative learning, active engagement, and the use of a variety of methods for learning has been reported to be highly effective (Dahlke et al., 2012). Common examples of cooperative strategies are peer teaching and pairing students for student-to-student instructions. Other effective 291behaviors include sharing anecdotal notes, using objective language when giving feedback, probing to help students self-correct misunderstandings, and communicating expectations clearly.

Effective Clinical Teaching Behaviors and Attitudes

Teaching behaviors that facilitate students’ development in higher-order thinking skills include prompts to help students recognize the salient cues in a situation, prioritization, retrieval, and application of theoretical and factual knowledge from coursework. Most importantly, effective clinical instruction focuses on helping students to think contextually with intent to understand the unique characteristics of the patient’s situation at hand (Benner et al., 2010). Included among motivational strategies are discussing course goals and relating them to the practicum arena, exhibiting enthusiasm about the profession, discerning student expectations, establishing reward systems, and trying new and different teaching strategies. Strategies that facilitate thinking modalities also include logic models (Ellerman, Kataoka-Yahiro, & Wong, 2006), case studies, and concept mapping. These strategies can be used in the classroom as a way to prepare students for clinical practice and to bridge the gap between didactic courses and clinical learning experiences.

Teacher behaviors relating to interpersonal skills are reported to affect student outcomes. Behaviors such as showing respect for students and treating students with respect (Dahlke et al., 2012), correcting mistakes without belittling), and being supportive and understanding are helpful.

Nursing students experience stress and anxiety in clinical learning situations (Elliott, 2002; Lo, 2002; Timmins & Kaliszer, 2002). Negative relationships with faculty can contribute to anxiety (O’Mara et al., 2014). The effective clinical teacher recognizes students’ need for supportive and collegial relationships and develops an interpersonal style that promotes a collegial learning environment; O’Mara et al., 2014). Positive relationships are nurturing and can enhance learning. Caring behaviors and a caring environment are also essential (O’Mara et al., 2014).

The literature points to the importance of building relationships between students and teachers. It is believed that the quality of their interaction affects learning outcomes (Tanner, 2005). Concepts that facilitate the building of relationships may include the following: connections, caring, compassion, mutual knowing, trusting and respecting, availability, knowledge, confidence, and communicating (Gillespie, 2002). By knowing the students’ strengths, challenges and individual goals, faculty are prevented from making assumptions and reacting to students’ misunderstandings or poor performance. Making assumptions regarding student intent or motivation may be perceived by students as being disrespectful. Making connections to identity early in the relationship assists faculty in determining the elements needed to meet students’ learning needs (Dahlke et al., 2012; O’Mara et al., 2014).

Teacher confidence is another factor that enhances learning; teachers who lack confidence actually create distance between themselves and the students they teach). This hinders the sense of knowing and the possible connections that may have formed. A part of teacher confidence is a foundation of knowledge. When clinical teachers use their expertise to support learning, the teacher–student relationship is strengthened.

Cook (2005) engaged in a study to explore perceptions of teacher behaviors that invite trust and create student anxiety. The findings indicate that teachers need to be aware of how their behaviors can be negatively perceived by students, thus influencing the anxiety that occurs during the clinical experience and ultimately affecting learning. Senior clinical faculty should serve as role models and mentor junior clinical faculty to create a legacy of effective clinical teaching. Additional characteristics of effective teachers are listed in Box 17-2.

Box 17-2

Characteristics of Effective Clinical Teachers

1. Create an environment that is conducive to learning that requires:

• Knowledge of the practice area

• Clinical competence

• Knowledge of how to teach

• A desire to teach

2. Be supportive of learners. Such support requires:

• Knowledge of the learners

• Knowledge of the practice area

• Mutual respect

3. Possess teaching skills that maximize student learning. This requires an ability to:

• Diagnose student needs

• Learn about students as individuals, including their needs, personalities, and capabilities

4. Foster independence and accountability so that students learn how to learn.

5. Encourage exploration and questions without penalty.

6. Accept differences among students.

7. Relate how clinical experiences facilitate the development of clinical competence.

8. Possess effective communication and question skills.

9. Serve as a role model.

10. Enjoy nursing and teaching.

11. Be friendly, approachable, understanding, enthusiastic about teaching, and confident with teaching.

12. Be knowledgeable about the subject matter and be able to convey that knowledge to students in their practice areas.

13. Exhibit fairness in evaluation.

14. Provide frequent feedback.

Preparing Faculty for Clinical Teaching

The preparation and development of faculty for clinical teaching are not as widely discussed and documented as the preparation of students for clinical learning. Studies indicate that the exposure of faculty to evidence-based teaching strategies and learning theory is minimal (Dahlke et al., 2012; McNelis et al., 2014). Krautscheid, Kaakinen, and Warner (2008) directed efforts to facilitate a reversal in this trend. A clinical faculty development 292program, developed to help faculty practice teaching by analogy and reflect on clinical teaching, was implemented. With this program, clinical teaching simulations were used to allow faculty to practice, teach, and receive immediate feedback. Scenarios were used to facilitate the process. As a result of the clinical teaching simulations, faculty reported being more reflective as teachers and practitioners and identified the importance of facilitating a safe learning environment in the clinical practice setting.

Expert clinicians often have a desire to teach in the practicum area. Providing the faculty development needs of expert clinicians can be challenging. It can be very difficult to equip clinicians with teaching skills required to be an effective clinical teacher for those faculty who also maintain full-time clinical practices. Some have been preceptors and to fully attain the skills needed to make the transition to a new role as clinical teachers, further instruction, coaching, and guidance is required. These individuals should be encouraged and provided with information about where and how they can engage in activities that will facilitate their acquisition of the knowledge and skills required for the clinical teaching role. Some schools have developed modules for that purpose.

One method for meeting the challenge of educating clinical teachers is to use an online course to orient clinicians who are making the transition from the role of expert clinician to that of clinical teacher (Reid, Hinderer, Jarosinski, Mister, & Seldomridge, 2013). Essential topics include teaching–learning theory, critical thinking, how to deal with challenging students, and making patient assignments. Because being an excellent clinical nurse does not mean that the nurse will be an excellent teacher, Cangelosi, Crocker, and Sorrell (2009) developed a Clinical Nurse Educator Academy to prepare clinicians for clinical teaching. After analyzing reflective papers at the end of the academy, the authors found that the nurses were enthusiastic about the educator role, but that the frustration from lack of mentoring indicates a need for ongoing development of the educator role.

In summary, effective clinical teachers are knowledgeable and know how to convey concepts to students in effective ways, are clinically competent, coach students to develop clinical reasoning and judgment, exhibit interpersonal skills that positively influence students’ learning, and establish collegial relationships that often last well beyond a specific course or program. Clinical faculty also need to be oriented to and developed for the role. Research is likely to continue in this area.

Preparing Students for Patient Care

Teaching for patient care should involve orderly and logical actions taken to accomplish particular educational goals. The actual selection and use of a particular strategy should be based on expected outcomes, principles of learning, and learner needs. This section focuses on several strategies commonly used in clinical teaching: patient care assignments, clinical conferences, nursing rounds, and written assignments.

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Students come to the health care environment not really understanding the culture of confidentiality. It is imperative that students know and understand the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security regulations. It is the role of faculty to instruct students on the need to implement the HIPAA rules and regulations in all patient encounters. They are designed to protect the patient’s right to privacy. Students should be informed of what they can and cannot do in relation to confidentiality, and these instructions must be enforced.

Patient Care Assignments

Patient care provides students with opportunities to integrate, synthesize, and use previously learned knowledge and skills. Some nursing courses require students to prepare in advance for their clinical experience. Advance preparation commences with making clinical assignments, which may be the responsibility of the clinical teacher, the teacher and student together (especially useful for beginning students), the student alone, the student with guidance from the teacher, or the nursing and health care staff or preceptors. Allowing students some input into selecting clinical assignments encourages them to be self-directed as well as to choose experience on the basis of their personal learning needs. Refer to Box 17-3 for other suggestions for making assignments.

Box 17-3

Tips for Making Assignments

New faculty often are at a loss in knowing where to begin. The following tips should assist new faculty to enhance their comfort level in implementing this task.

• Come to the unit with knowledge of specific student needs.

• Have an assignment sheet with a list of the students for the given day.

• Get input from those in charge and from the staff nurses.

• Talk to the nurse in charge and ask for brief suggestions about the patients on the unit. This simple act of communication is one way to build a trusting, supportive relationship with the staff on the unit, as they can be very helpful in guiding what patients will make for a good assignment.

• Make rounds and talk to all of the patients and family you plan to care for on the following day. Just a few minutes chatting can assist you in deciding whether a patient will be appropriate for a student nurse.

• Obtain patient and family permission, as this may prevent early morning assignment changes because a patient refuses to have a student.

• Consider the specialty on your particular unit. Knowing the patient population will help determine when to make assignments. For example, if it is a surgical unit, you may want to make assignments later in the afternoon because patients may be admitted late to the unit following surgery. If you make an assignment too early, you may risk the problem of a patient being reassigned to a different unit or discharged.

• Be sure that students know who the charge nurse is in case the assignments need revision when faculty are not available. Establishing a protocol for this will lessen frustration among the staff.

• Always have a backup plan. Add a couple of extra patients to the assignment sheet in case something changes when faculty are not available.

The selection of clinical assignments by students in collaboration with others has several benefits. It provides opportunities for students to select experiences that are based on personal learning needs, to experience a degree of control over their education, and to interact with practicing professionals during the process of selecting experiences. The extent to which students are permitted to self-select experiences depends on the goals or expected outcomes of the program, the philosophy of the specific clinical teacher, and the availability of resources in the clinical environment to assist students (i.e., to answer questions and provide guidance in patient selection).

Involvement of the clinical faculty is important when students select their experiences. For example, faculty serve as resource advisers and sources of emotional support, communicate goals and intended outcomes, assist students in assessing the congruency between personal learning needs and course objectives, facilitate planning the experiences, collaborate with students as they strive to meet goals, and evaluate accomplishments. Making clinical assignments can be a challenge for clinical faculty. Novice faculty are often at a loss in terms of knowing where to begin. This is where mentoring by senior-level or expert faculty is helpful.

Strategies for Implementing Clinical Assignments

Clinical assignments are an integral part of nursing practicum experiences. Several strategies for making clinical assignments have been adopted for 294clinical teaching. The strategy used in clinical instruction is often determined by factors such as the skill level of the student, the patient acuity level, the number of assigned students, and the availability of patients and resources, including the availability of technology. Traditional and alternative strategies, such as dual assignments, multiple assignments, and clinical conferencing, are discussed.

The traditional strategy is one in which nursing students are taught in a clinical setting with a varying faculty-to-student ratio. Ratios should be determined with an aim for facilitating optimum learning, knowledge of regulatory and agency requirements, and consideration of the workflow of the unit or agency. Most importantly, consideration of patient safety and quality care is essential (Ironside & McNelis, 2010; McNelis et al., 2014). The rationale for these ratios relates to the effect of increased numbers of students on patient safety (Ironside & McNelis, 2010). From a student’s perspective, this strategy involves the assignment of one student to one or two patients. The students assume responsibility for the nursing interventions needed in the care of the patient and may work alone in planning, implementing, and evaluating nursing activities.

Alternatives to the traditional method of clinical assignment are dual and multiple assignments. The dual assignment strategy (Fugate & Rebeschi, 1991) involves assigning two students to one patient. This alternative is useful when the level or complexity of care is beyond the capabilities of one student. Because students must work closely to implement care, collaboration and communication between the students are requisites for effective use of this strategy. Benefits of this strategy include improved time management, opportunities for collaboration and peer support, and fewer numbers of patients for which the faculty is responsible. When dual assignments are made, faculty have the responsibility of ensuring that each student understands his or her specific responsibility. For 2-day clinical rotations, roles may be reversed on the second day of care). Such reversal makes it possible for both students to direct care to the patient.

The strategy of multiple assignments is useful for beginning students and in situations where a limited number of patients are available. This strategy involves the assignment of three students per patient. Three roles are assumed: the doer who provides the care; the information gatherer or researcher who is responsible for obtaining information needed for the safe care of the patient; and the observer who observes the student, the researcher, the student–patient interactions, the responses of the patient to his or her care, and the family members. The observer also makes suggestions for improving care. As with dual assignments, the roles for each student must be clearly defined. Adequate time must be made available for collaboration and discussion among students and faculty.

The multiple assignment approach must meet learning objectives. Glanville (1971) conducted a study to determine the effectiveness of this method as an approach to clinical teaching. Results revealed similarity in the extent to which objectives were met and in the levels of achievement for students assigned to the multiple assignment approach and those assigned to the traditional method. VanDenBerg (1976) randomly assigned 22 first-year associate degree students to two groups, one of which used traditional assignments and one of which used multiple assignments. Results showed that students assigned to the multiple assignment group demonstrated a significant increase in nursing knowledge compared with those assigned to the traditional group.

In light of the increasing complexity of learning environments and the instability of the patient census, consistent clinical assignments and multiple placement assignments were compared to determine learning outcomes (Adams, 2002). Here, consistent means that students were assigned to a unit for a specific time frame or used more than one unit during the period. Quantitative measures revealed no difference in the two methods of clinical rotation. However, the perceptions of the benefit of consistent clinical assignments were positive.

In summary, faculty, staff, and students play a significant role in determining assignments. Assignments are made according to a number of factors, including course objectives, learner needs, skill level, complexity of the clinical environment, and patients’ acuity. The assignments may be implemented as solo or multistudent experiences. Each has been considered beneficial in enhancing learning.

Clinical Conferences

Clinical conferences are group learning experiences that are an integral part of the clinical experience. The use of clinical conferences in nursing is common. Conferences can provide meaningful 295learning experiences and excellent opportunities for students to bridge the gap between theory and practice. Through conferences students can develop critical thinking and clinical decision-making skills (Wink, 1995) and acquire confidence in their ability to express themselves with clarity and logic.

Successful clinical conferences are planned. Plans for conferences should take into consideration the curriculum and the learner. An identification of the purpose, topic, process, strategies, and methods of evaluation are essential if the teacher is to be instrumental in bridging the gap between theory and clinical practice.

Types of Conferences

The conferences can include traditional preclinical, midclinical, and postclinical conferencing. As a result of advancing technology, conferences may take place through electronic media and online. As such, the rules and regulations related to HIPAA and the Health Information Technology for Economic and Clinical Health Act apply to clinical groups that use clinical conferencing by electronic media. Student groups must be aware of maintaining patient confidentiality as the group presents patient data by electronic means. Using this form of conferencing is a means of using technology while supporting the needs of students. Some may be doing clinical assignments at different sites and electronic conferencing brings students together where debriefing can occur without having to travel to a central location.

Traditional Conferences

Preclinical, midclinical, and postclinical conferences by nature are small-group discussion periods that immediately precede, occur during, or follow a clinical experience. Each provides opportunities for discussion. In preclinical conferences, students share information about upcoming experiences, ask questions, express concerns, and seek clarification about plans for care. Preclinical conferences also provide opportunities for faculty to correct student misconceptions, identify problem areas, assess student thinking, and identify student readiness to implement care.

Midclinical conferencing, in contrast to preclinical and postclinical conferencing, is another form of gathering students together to provide some form of midclinical debriefing. It has been found that, while doing a 12-hour clinical day, this gives students an opportunity to gather to share pertinent patient information and plan for further interventions, which may include patient teaching and discharge planning. This midclinical conference time also may help students collectively evaluate the efficacy of prior patient interventions. This exchange of data, in the form of a midconference, is a method of imparting knowledge and sharing common data with the intent of positively affecting patient care.

Postclinical conferences provide a forum in which students and faculty can discuss the clinical experiences, share information, analyze clinical situations, clarify relationships, identify problems, ventilate feelings, and develop support systems. In postclinical conferences there is interaction between the teacher and the students, which offers both a medium for learning and an exchange resulting in meaningful experiences.

Online Conferences

Online conferencing, occurring before or after clinical experiences, can assist students to come together in a virtual environment to exchange ideas, solve problems, discuss alternatives, and acquire information about issues of clinical care that occurred before or during the clinical experience (Gaberson, Oermann, & Shellenberger, 2015). See Chapter 21 for further discussion of teaching in online learning communities.

Student and Faculty Roles during Conferences

Both students and faculty have specific roles in conferences. Student should be made aware of their role as active participants. As such, they should defend choices of care, clarify points of view, explore alternatives, and practice decision making. A student may also assume the role of group leader. Faculty serve as conference facilitators by supporting, encouraging, and sharing information; posing questions and asking for alternative hypotheses; giving feedback; helping students identify patterns; and guiding the debriefing process. As conferences are facilitated, efforts should be made to ask higher-level questions that assist students in applying knowledge to clinical situations (Gaberson et al., 2015). Conferences also provide opportunities for students to apply group processes and develop team-building skills.

Evaluating the Conferences

Conferences should be evaluated in light of their effectiveness and goal accomplishment. The teacher should obtain and provide feedback regarding the extent to which goals were accomplished, the effectiveness of the teaching methods or strategies, and the 296degree of learning achieved. The data from the evaluation can be used for planning future conferences.

In summary, traditional and electronic conferences play a significant role in facilitating students’ learning. Conferences afford opportunities for enhancing critical thinking, clinical reasoning, and decision-making skills; for creating new meaning for care issues; and for enhancing group process and team-building skills. Successful conferences are planned. Inherent in planning are identifying the purpose, selecting topics, selecting teaching methods, and conducting and evaluating these methods.

Complementary Clinical Experiences

Nursing Grand Rounds

The practice of nursing grand rounds is a teaching strategy that uses the patients’ bedside for direct, purposeful experiences. These experiences may involve demonstration, interview, or discussion of patient problems and nursing care. Rounds also afford an excellent opportunity for the exchange of ideas about patient care situations, which may involve clinical faculty, students, and staff.

The use of rounds as a teaching strategy requires planning. Planning includes obtaining permission from the patient and providing information about the nature of the rounds and the role the patient will play. After the session, patient participation should be acknowledged and some form of debriefing should occur, including planning for subsequent rounds.

Concept-Based Learning Activities

Concept-based learning activities are a type of experience used recently in clinical education (Gubrud-Howe & Schoessler, 2009; Nielsen, 2009; Nielsen, Noone, Voss, & Matthews, 2013). This learning activity is designed to develop deep learning and pattern recognition of a particular health problem or medical diagnosis. Concepts are identified for students to study in the context of the patient care environment. Fluid and electrolytes is an example of a concept students may explore. Each student completes an in-depth assessment of a patient with a fluid and electrolyte problem. The pathophysiology, treatment, pharmacology, and patient response to care is explored. The faculty facilitates comprehensive discussion of each case and directs discussion so students begin to see the similarities and differences between each patient in an effort to begin to identify salient findings related to each case. The faculty help students identify unexpected findings in the patients’ situation related to the concept being studied and help students recognize current or potential complications that need to be addressed. Students are not responsible for care but need to address any safety issues that emerge as they are assessing their assigned patient. This activity allows the student to focus on critical thinking about the concept being studied without the distraction of attending to tasks associated with general patient care (Nielsen et al., 2013). Communicating the focus of this assignment and learning activity with staff is essential to avoid misunderstanding of the student’s role on the unit (Gubrud-Howe & Schoessler, 2009).

Written Assignments

Written assignments generally complement clinical experiences and are considered to be useful in that they facilitate development of critical thinking and clinical reasoning and they promote an understanding of content. Such assignments may include short papers, clinical reasoning papers, nursing care plans, clinical logs, journals, and concept maps. Findings from research on the use of clinical logs indicate that their use provides opportunities for students to reflect on clinical experiences, communicate with the teacher, identify mistakes and negative experiences, and learn from these experiences. See Box 17-4 for possible journaling questions.

Box 17-4

Sample of Journaling Questions

• How did you feel about your clinical day?

• What was the best part of your clinical day?

• What did you feel most confident about?

• If you could do your clinical day over, what would you do differently?

• What were you most concerned about as related to your patient’s care?

• What did you learn today that can apply to future patients with similar problems?

• What do you need to learn more about?

• Describe interactions with other professions. What went well? Describe how the interaction was or was not patient centered.

• Describe any patient quality or safety issues you had to address or manage. What goals do you have for your next clinical day?

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Point-of-Care Technology and Mobile Health

Nurses are increasingly using handheld devices, electronic health records, and other point-of-care technologies in the clinical setting, and faculty must provide opportunities for students to become familiar with their use. Simulated electronic health records can be embedded in clinical simulations as preparation for their use in the clinical agency or as a substitute for learning when agency policy precludes students’ use of them in the agency. Smart phones equipped with reference software enable access to clinical information; care plans; and nursing, procedure, and evidence-based practice guidelines; and can provide access to skills videos and patient teaching materials (Zurmehly, 2010). Increasingly, nurses are using software applications (“apps”) on a smartphone to diagnose, monitor, and teach patients in community-based settings; students must have experience using these point-of-care and mobile health technologies as well. See Chapter 19 for information about policies for using technology in clinical settings.

Models for Clinical Education

Several models for clinical education are used to educate nursing students. These models, alternatives to the traditional model, include preceptorship, associate model, paired model, academia–service partnerships, and adjunct faculty joint appointments. These models have evolved to increase capacity for clinical placements, facilitate development of competency for today’s practice, manage faculty shortages, prepare graduates to be competent for practice, and foster closer ties with clinical agencies (Delunas & Rooda, 2009; Murray, Crain, Meyer, McDonough, & Schweiss, 2010; Neiderhauser, Macintyre, Garner, Teel, & Murray, 2010; Niederhauser, Schoessler, Gubrud-Howe, Magnussen, & Codier, 2012; Nielsen et al., 2013). Given the diversity of health care settings, faculty shortage, and the need for reduced faculty-to-student ratios, new models serve to enhance effective student learning, facilitate development of clinical skills, and promote role development.

Preceptorship

Preceptorship is a teaching model in which the student is assigned to a nurse who serves as a preceptor. Preceptors are experienced nurses who facilitate and evaluate student learning in the clinical area during a specified time. Their role is intentionally implemented in conjunction with other responsibilities related to patient care in the clinical environment. The preceptor model is based on the assumption that a consistent one-on-one relationship provides opportunities for socialization into practice and bridges the gap between theory and practice. The preceptor model may be used at several levels. However, it is considered to be particularly useful for senior-level students and graduate students in advanced practice roles. Use at these levels provides opportunities for students to synthesize theoretical knowledge and apply information, including evidence-based research, in the practice environment. This method is also an excellent way for students to practice collaboration.

Theoretically, the preceptor provides one-on-one teaching, guidance, and support, and serves as a role model. In one model (Billings, Jeffries, Rowles, Stone, & Urden, 2002), the preceptor, faculty, and student form a triad to facilitate the student’s acquisition of clinical competencies. The preceptor may be assigned to a student on the basis of shared learning needs. The preceptor and student meet before the first clinical experience to discuss learning styles and goals for competency attainment and the desired outcome of the clinical experience. Although faculty have ultimate responsibility for the course and students’ learning outcomes, the student and preceptor are empowered to conduct formative and summative evaluations of the student’s clinical performance and learning outcomes. In the Integrative Clinical Preceptor Model (Mallette, Laury, Engleke, & Andrews, 2005; Mamhidir, Kristofferzon, Hellström-Hyson, Persson, & Mårtensson, 2014), the student assumes a proactive role, not only as a student, but also as a member of the health care team. In this model, the preceptor assumes responsibilities as a clinical teacher, mentor, and role model, and faculty serve as a role model and facilitator for the preceptor and the student as well as a consultant.

Preceptors are expected to be clinical experts, to be willing to teach, and to be able to teach effectively (McClure & Black, 2013). Benefits that have been derived from preceptorships include enhanced ability to apply theory to practice, improvement in psychomotor skills, increased self-confidence, and improved socialization. Attributes of an effective preceptor are listed in Box 17-5.

Box 17-5

Attributes of an Effective Preceptor

1. Knowledge of the patient care area

2. Effective communication skills (verbal and nonverbal)

3. Experience in a particular clinical area

4. Ability to relate to health care personnel and client

5. Honesty

6. Effective decision-making skills

7. Genuine caring behaviors

8. Leadership skills

9. Interest in professional development

Used with permission from Lewis, K. E. (1986). What it takes to be a preceptor. The Canadian Nurse/L’infirmière Canadienne, 82(11), 18–19.

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In a preceptorship, the role of the nursing faculty transitions from direct instruction to an emphasis on facilitation and evaluation. Preceptors and faculty must work in a close relationship). Faculty provide the link between practice and education. In providing this link, faculty monitor how well the students complete assignments and accomplish outcomes. Evaluation is a collaborative responsibility of faculty, students, and preceptors but most nurse practice acts require the faculty to assume accountability for evaluating the student’s attainment of learning outcomes.

The use of preceptors requires that planning be done to ensure an understanding of their role. Ideally this is facilitated through strategically planned orientation and follow-up sessions; some schools of nursing offer workshops or courses to orient preceptors to their role (McClure & Black, 2013; Smedley & Penney, 2009). These sessions provide a forum for sharing information related to the philosophical perspectives of preceptorship, expected outcomes, teaching strategies, and methods of evaluation. Because roles change for faculty, students, and preceptors, all require orientation to new roles (McClure & Black, 2013; Mallette et al., 2005).

The value of the preceptor model is generally related to providing students a sense of independence for patient care and the ability to develop a professional identity. Preceptors and clinical agencies also value the preceptor model because preceptors develop additional skill sets related to teaching and the clinical agency that stands to benefit from hiring a well-prepared graduate.

Clinical Teaching Associate

The clinical teaching associate (CTA) model involves a staff nurse who collaborates with a designated faculty member and instructs a specified number of students in the clinical area (Baird, Bopp, Schofer, Langenberg, & Matheis-Kraft, 1994; DeVoogd & Saldbenblatt, 1989). Teaching responsibilities are assumed by the CTA, who also serves as a resource person and role model. A faculty member serves as lead teacher and is responsible for supervision and evaluation of clinical learning experiences, including assignment of grades and collaboration with the CTA about assignments and experiences.

Results from a survey of nurse managers, CTAs, faculty, and students conducted to determine the effectiveness of this model were positive (Baird et al., 1994). Positive comments were presented in terms of student learning. Patient satisfaction with care was reported to be greater than with the traditional model. Nurses in the CTA role reported an increase in student confidence. Faculty reported that students were more relaxed and more self-confident. The effectiveness of the model was reported by students as allowing them to assume increased responsibility in comparison with the traditional model.

Paired Model

The paired model is designed to pair a student and a staff nurse for a practicum experience. It is an alternative to the one-patient, one-student model and is a variation of the preceptor model. This model is often used in combination with the Dedicated Education Model and in community-based setting such as an ambulatory care center or clinic. During the course, each student has a specified number of days in a paired relationship. The remaining time is spent acquiring experiences by using the traditional model. The staff nurse plans the learning experience; the faculty member oversees the experiences while creating a learning environment for students. However, most of the faculty member’s time is spent in the traditional role with other students who have not been paired. To enhance the effectiveness of the paired model, it is essential that the staffing pattern be evaluated before making assignments.

Academia–Service Partnerships

The clinical teaching partnership is a collaborative model shared by service and academia settings to enhance mutual goals of developing nurses 299competent for practice and creating safe practice environments. Partnerships are also formed to create new models of clinical instruction and increase student and faculty capacity in nursing programs (Delunas & Rooda, 2009; Nielsen et al., 2013). Although these partnerships take different forms, they are established collaboratively and result in redesigned clinical education experiences for students and faculty as well as for the nurses at the clinical agency. Academic and service partnerships are a promising framework to address the nursing faculty shortage.

In one early partnership model, the service institution shared the resources of nurses, a clinical nurse specialist (CNS), and an academic faculty member (Shah & Pennypacker, 1992). The CNS serves as an adjunct faculty member who provides patient assignments. The academic faculty member schedules the experiences. Jointly they collaborate in evaluating assignments facilitating learning experiences and assessing students’ performance. Communication is reciprocal and essential to the success of this model. The faculty member shares information about problems that may influence students’ performance. The CNS keeps the faculty member abreast of current student performance. Both schedule conferences to discuss anecdotal records of students. Murray et al. (2010) report that students in their partnership model were better integrated into the clinical setting and increased levels of critical thinking and clinical decision making.

Adjunct Faculty

Adjunct faculty are health care professionals who are employed in the service setting and have a part-time academic appointment. Adjunct faculty may assume various roles, including those of preceptor, CTA, mentor, guest lecturer, and supervisor. These individuals may also collaborate on research projects. Faculty who are appointed in an adjunct capacity are registered professional nurses or professionals who are experts in areas such as clinical practice, research, leadership, management, legislation, and law.

Dedicated Education Units

Over the past decade, the dedicated education unit (DEU) model has been implemented at various universities across the country. Moscato, Miller, Logsdon, Weinberg, and Chorpenning (2007) indicate that the “DEU offers a concrete strategy to more closely connect nursing units and education programs” (p. 32). DEUs involve new partnerships among nurse executives, staff nurses, and faculty for transforming patient care units into environments designed to support learning experiences for students and staff nurses while continuing the critical work of providing quality care to acutely ill patients. Mulready-Shick, Flannagan, Banister, Mylott, and Curtin (2013) found that the DEU model facilitates stronger relationship building between nurses in academia and practice, and students report significantly more positive learning experience when compared with traditional clinical placement experiences. Universities are implementing this strategy in a variety of ways. One Midwest university uses the term practice education partnership (PEP) units. The PEP unit is a hospital-based unit designed to provide the student with a strong partnership between the practice and education settings. The PEP model differs from the Australian DEU model in that it works to incorporate the culture of the unit and its clinical specialty into the availability of preceptors, level of patient acuity, and other influences on the education of the student. One of the unique aspects of the PEP model is that there is continuity and consistency among preceptors, faculty, and students as they partner to learn and grow together. Preceptors are coached on preceptor competencies by attending a full-day workshop. It is at this time that the partnership between the nurse and the faculty begins. This partnership is developed over time and ultimately the student learns the role of the nurse and together the student and preceptor provide exceptional patient care.

The use of DEUs has increased significantly in the last decade (Moscato, Nishioka, & Coe, 2013). Research indicates the educational quality and competency development are significant for students receiving clinical instruction in DEUs (Dapremont & Lee, 2013; Mulready-Shick et al., 2013).

Residency Models

Recognizing that prelicensure programs may not be sufficient for preparing nurses for practice in complex health care settings, several studies and commissions (Benner et al., 2010; Institute of Medicine, 2010; Tanner, 2010) report on the need for postgraduate residencies and call for their increased use to improve transition to practice and development of leadership and population management skills. Accreditation and regulatory standards have been developed for this 300approach to residency. The American Association of Colleges of Nursing (AACN) developed a 12-month program designed to facilitate further development of competency and ease the transition into practice. The AACN piloted six programs in 2004 and there are now residency programs in more than 30 states (Barnett, Minnick, & Norman, 2014). The NCSBN developed a model that provides a framework for standardized transition to practice and regulatory guidelines are under consideration (Goode, Lynn, McElroy, Bednash, & Murray, 2013).

Several studies have been conducted to examine the outcomes of nurse residency programs (Goode et al., 2013). The findings suggest nurse residency programs increase overall confidence and competence particularly in the ability to organize, prioritize, communicate effectively, and provide leadership (Goode et al., 2013). Residency programs have a statistically positive influence on nurse retention rates (Goode et al., 2013). Further research is needed to determine the influence of postgraduate nurse residency programs on patient outcomes (Barnett et al., 2014).

Summary

In summary, several models for clinical education of student nurses exist. Alternative models, collaborative in nature, have evolved because of the increasing complexity of the health care environment. Among these models are preceptorships, the teaching associate model, the paired model, clinical teaching partnerships, and adjunct faculty. The nature of each model dictates the level of student that would benefit most. The paired and clinical associate models have been used for beginning students, whereas the preceptorship model is widely used for students in the upper level of their program and for graduate students. Empirical research on the effectiveness of these models has been sparse; there is a need for further evaluation of and research on these models in terms of their effectiveness on student learning and preparation for the workforce.

Clinical teaching involves student–teacher interaction in experiential clinical situations that take place in diverse and often interprofessional practice environments. These environments may include laboratory, acute care, transitional, and community sites, including homeless shelters, clinics, schools, camps, and social service agencies. Faculty must have in-depth knowledge of teaching behaviors that facilitate students’ learning and development, and have complete knowledge of the culture of the practice area as well as the health care provider. Effective clinical teachers are able to plan, facilitate, and evaluate experiences using instructive, interpersonal, and evaluative strategies. These strategies facilitate faculty’s acquisition of the knowledge and skills required to become nurses.

A variety of teaching methods can be used to enable students to achieve desired outcomes. Patient assignments, clinical conferences, nursing grand rounds, concept-based clinical activities, and written assignments are among these. The skill level of students, patient’s acuity level, number of students, and patient care resource availability will affect the method used. Among the models suggested for educating nursing students are the traditional approach and alternatives to this model, including preceptorships, CTAs, teaching partnerships, and adjunct faculty. Practicum experiences prepare students for working in a health care system that is evidence based and patient centered. Teaching in the practicum setting blends faculty’s clinical expertise with teaching skills to prepare nurses for current and future roles in an ever-changing health care system.

Reflecting on the evidence

1. Choose a set of clinical teaching strategies for a group of students. What do you need to consider about the student, the setting, and the patients in order to make this decision? What evidence for practice will you draw on to make your decision?

2. What is the role of Internet-based teaching and learning in clinical teaching? Can clinical practice be learned in a fully online course?

3. What is the state of science about clinical teaching? What research questions are being asked? What methods are being used? What variables are included in the studies?

4. What are the best practices that are evidenced-based?

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