Strategies for Teaching Clinical Nursing

E Book

Acknowledgements

This curriculum, which is meant as an overview to teaching andlearning strategies essential to the new clinical instructor, is adaptedfrom the works of Andrea B. O'Connor. Her text is an extremelyvaluable teaching guide for part-time faculty who are expert clinicianswith a strong interest in teaching, but with little preparation for the roleof nursing educator. The following textbook is strongly recommendedin addition to this CD-ROM:

O'Connor, A. (2001) Clinical instruction and Evaluation: A teachingresource. Boston: National League for

Nursing.

Preface

Teaching, like nursing, is a combination of art and science. It issomething that must be learned. The science of teaching refers tothe various principles and strategies necessary to provide high-qualityeducational experiences. The actual application of these methods isthe skill or art of the profession. The purpose of this CD-ROM is toprovide necessary theory and minimal skill development required ofexperienced nurses new to the clinical instructor role.

Although nursing education programs rely on competent clinicalinstructors, it is neither practical nor economically feasible to maintaina roster of full-time clinical faculty. Content expertise, as is requiredof clinical nursing faculty, generally does not provide the instructionalcompetencies required to deliver high-quality educationalexperiences. Therefore, this program is intended to provideinstructors who are new to the system with some basic survival skillsto see them through their initial teaching assignments.

Unit I: Clinical Nursing EducationGoalsThe overall goal of clinical nursing education is to prepare studentsfor future practice through learning experiences that provideopportunity for integration of theoretical with practical knowledge. Asa role model, the instructor assists the student to think like aprofessional nurse by helping the student to:

- think critically- communicate accurately- perform indicated therapeutic nursing interventions in patient

care situations- exhibit caring behaviors inherent in nursing actions- apply an ethical perspective in clinical decision making- function effectively as a collaborative team member within the

organizational structures surrounding the delivery of patientcare

The overriding task of the teacher in the clinical setting is competentguidance. The teacher supports, stimulates, and facilitates studentstowards personal and course objectives (Gaverson, K. & Oermann,M., p.2). According to Infante (1985), the teacher facilitates learningby designing appropriate activities in appropriate settings andallowing the student to experience that learning.

The instructor is both student advocate and patient advocate. Whilecoordinating care activities for students to perform successfully in theclinical area, the clinical instructor must maintain an awareness ofcontent level-specific knowledge, skills, and attitudes to be masteredthrough the clinical learning. At the same time the instructor isalways attentive to ensure patient safety.

Unit 2: Theoretical Approaches toLearning

Excellence in instruction requires knowledge of adult educationmethods, adult learning, as well as the design and selection ofappropriate learning activities.

The Adult Learner

Before an effort is made to teach anyone, especially an adult, it isimportant to understand the learner’s background -- where he or sheis coming from. There are several characteristics that are crucial tothe understanding of the adult learner profile.

The instructor first must understand that is highly likely that an adultlearner may have a family in which he or she is fully or at leastpartially responsible. Spouses, children, perhaps even parents orother family members, may directly rely upon the student foremotional and/or financial support.

It is also important to recognize certain employment characteristicsthat may affect the student. The student may be:

- Unemployed- Under-employed- A career changer- Looking to be promoted- Interested in learning new skills- Retired- New to the United States

There is quite a large difference between child/adolescent learnersand adult learners. While child/adolescent learners tend to be ahomogeneous group comprised of students of generallyundifferentiated backgrounds, educational levels, experience, andage, adult learners are a highly differentiated group of individualsfrom a wide variety of backgrounds, diverse educational levels,

experience, and ages.

Child learners and adult learners also experience a different thirst forlearning. Child learners are a captive audience in an educationalsetting. Generally, child learners are in school because they have tobe; they are forced to learn and are not usually allowed to get up andleave the classroom whenever they feel like. They also are stronglycommitted to learning because they see themselves as dependent onothers and can therefore focus on studies.

In contrast, adult learners are a voluntary audience. Adult learnersare in school because they want to be there; no one is forcing them tostay in the classroom. They stay because of a desire to learn.However, while important, their education is often viewed assecondary to other responsibilities because adults view themselvesas independent, self-directed, and responsible for themselves andothers (i.e. family members).

Child learners are often vastly inexperienced, whereas adults tend tohave great experience at a great many things. They have often helda wide variety of jobs and occupations, worked with many differentemployers and employees, and are genuinely proud of thisexperience. The adult learner and his/her experiences should beconsidered an asset to the instructor because they are a greatresource for the instructor and classmates.

Child/Adolescent learners are also concerned more about learning forthe future, and learning what is recommended. Adult learners arefocused more on immediate goals and training needs. Adults do notgenerally enroll in training programs out of general interest. Theyknow what they need to learn and will not be satisfied unless they aretaught what they need to know. Thus, an instructor cannot usuallydivert from class objectives when teaching adult learners.

Adult Education and Learning

Adult learning is about the promotion of active learning grounded inthe past experience of the learner. The adult approaches theclassroom with his own knowledge acquisition and needs to be ableto integrate new ideas with what he already knows if he is gong to

keep -- and use-- the new information. An educator's job is to helpthe learner add to and reorganize his own thoughts and skills, not tofill an empty vessel or clean slate. The presentation of new datashould be meaningful, and it should include aids that help the learnerorganize it and relate it to previously stored information. Newknowledge has to be integrated with previous knowledge; that meansactive learner participation.

Physiologic differences due to the aging process and developmentaldifferences are two of the many variables which impact the designingof a curriculum and classroom presentations or activities for adultlearners. To maximize the classroom experience, the learningenvironment must be physically and psychologically conformable.Physiologic challenges due to the aging process, such as diminishedhearing and vision, must be taken into consideration. The roomshould be well lit. The font of lettering on the white board,overhead presentations, and flip charts must be clearly legible fromthe rear of the room.. Distracting noises should be eliminated. Theinstructor must enunciate clearly and loud enough to be heard fromthe last row. Adults report that long lectures, periods of interminablesitting and the absence of practice opportunities are high on theirritation scale.

Additionally, the curriculum designer must know whether theconcepts and ideas will be in concert or in conflict with the learners'developmental stage. The classroom is likely to be a heterogeneouscohort depicting stages of Piaget's Cognitive Development Theory --concrete operations as well as formal operations. The former arestudents whose logical thinking is related to concrete tasks that areimmediate and physically present. The latter are capable of abstractreasoning. Programs must be developed to promote learning andaccept viewpoints from people in different thought stages.

Adult Learning Theory Principles & LearningDomains

Adult learning is about the promotion of active learning grounded inthe past experience of the learner. Therefore, it is important for theinstructor to respect individuality, privacy and dignity; provide positive

role models; give positive feedback to students on specific behaviors;include ethical behavior in student assessment; continually debrief;and be sensitive to complexities associated with cultural and/orlanguage barriers.

Learning occurs in three learning domains. The cognitive domainrefers to understanding, the affective domain refers to attitudes, andthe psychomotor domain refers to kinesthetic (motor skills) ability.Learning may involve one, two, or all three of these domains. Thecharacteristics of learning within each domain greatly affect theteaching and evaluation methods used. It is crucial that the instructorunderstand each learning domain so that the instructor can selectproper teaching techniques. The instructor must also be able toapply certain basic learning principles to any teaching method.

Basic Learning Principles

Learning depends on a student’s motivation to learn, a student’sactive participation, a student’s ability to learn, and the learningenvironment, including both internal and external factors.

The learning environment, i.e. the classroom, can and should beused to focus the student’s attention on what needs to be learned.Teacher’s who create warm and accepting, yet business-likeatmospheres will promote persistent efforts and favorable attitudestowards learning.

Regarding motivation, certain incentives, such as receiving praisefrom an instructor, can significantly improve student motivation tolearn. However, some form of internal motivation is longer-lastingand more self-directive than external motivation. If the studentexperiences feelings of satisfaction to what she is learning, herreadiness to learn increases, as does her participation.

When dealing with adult learners it is best to limit the number ofcompletely new and foreign concepts. While an adult’s thirst forlearning may be greater than that of a child, as an adult grow older,the ability to learn completely new concepts becomes increasingdifficult. For example, it is much easier to learn how to speak aforeign language while growing up than it is to learn one as an adult.

That is not to say it is impossible, but it becomes increasingly difficultwith age. Therefore, to aid a student’s ability to learn and retain asmuch as possible, it is best to relate new concepts to something thatthe student already knows or with which she is familiar.

Learning Styles

There are three primary learning styles: visual, auditory, andkinesthetic. The visual learner is taught best through a more visuallyengaging medium, such as textbooks, overheads, handouts, PowerPoint presentations, etc. The auditory learner learns best throughspoken communication such as conversations, speeches, andlectures. The kinesthetic learner learns best through doing anactivity, learning a skill – any tangible method of learning. Thelearning style determines both how the student approaches learningas well as how the student applies certain methods.

It used to be that researchers considered these learning styles ascompletely separate. One was either solely a visual, auditory, orkinesthetic learner. While in some cases this is true, researchershave found that students are actually more of a combination of theselearning types. It has become increasingly rare that a student fits oneparticular learning style. However, students tend to be moredominant in one style than in another. Most students are aware oftheir particular strengths in learning, but because students varygreatly and are often combinations of these varied learning styles, itis important to try one’s best to teach to all three learning styles.

In the college setting, generally the auditory and visual learners aretaken care of with a lecture combined with visual aids, but kinestheticstudents are often disregarded. However, there is a growing trend tofocus more on kinesthetic learning through various activities, and nowthrough the advent of multimedia teaching, as researchers arediscovering that multimedia, if done properly, can teach to all threelearning styles (See Appendix A for more information on learningstyles and suggestions for teaching to the various learning styles).

Seven Principles for Good Instruction

In a research project co-sponsored by The American Assocation ofHigher Education, the Education Commission of the States and TheJohnson Foundation, Chickering and Gamson (1987) compiled theSeven Principles for Good Practice in Undergraduate Education.These guidelines were identified in answer to the question, “Whatdoes research indicate about the conditions that produce goodlearning?" According to data analyzed by Chickering and Gamson,when these principles are implemented, teaching and learning usuallyimprove.

1. Good Practice Encourages Contacts Between Students andFaculty

Frequent student faculty contact in and out of class is a mostimportant factor in student motivation and involvement. Facultyconcern helps students get through rough times and keep onworking. Knowing a few faculty members well enhancesstudents' intellectual commitment and encourages them to thinkabout their own values and plans.

2. Good Practice Develops Reciprocity and Cooperation AmongStudents

Learning is enhanced when it is more like a team effort than asolo race. Good learning, like good work, is collaborative andsocial, not competitive and isolated. Working with others oftenincreases involvement in learning. Sharing one's ideas andresponding to others' improves thinking and deepensunderstanding.

3. Good Practice Uses Active Learning TechniquesLearning is not a spectator sport. Students do not learn muchjust sitting in classes listening to teachers, memorizingprepackaged assignments, and spitting out answers. They musttalk about what they are learning, write reflectively about it, relateit to past experiences, and apply it to their daily lives. They mustmake what they learn part of themselves.

4. Good Practice Gives Prompt FeedbackKnowing what you know and don't know focuses your learning.In getting started, students need help in assessing theirknowledge and competence. Then, in classes, students needfrequent opportunities to perform and receive feedback on theirperformance. At various points during college, and at its end,students need chances to reflect on what they have learned,what they still need to know, and how they might assessthemselves.

5. Good Practice Emphasizes Time on Task:Time Plus energy equals learning. Learning to use one’s timewell is critical for students and professionals alike. Allocatingrealistic amounts of time means effective learning for studentsand effective teaching for faculty.

6. Good Practice Communicates High Expectations:Expect more and you will get it. High expectations are importantfor everyone – for the poorly prepared, for those unwilling toexert themselves, and for the bright and well motivated.Expecting students to perform well becomes a self-fulfillingprophecy.

7. Good Practice Respects Diverse Talents and Ways ofLearning:

Many roads lead to learning. Different students bring differenttalents and styles to college. Brilliant students in a seminarmight be all thumbs in a lab or studio; students rich in hands-on experience may not do so well with theory. Students needopportunities to show their talents and learn in ways that workfor them. Then they can be pushed to learn in new ways thatdo not come so easily.

William Glasser

William Glasser, one of the foremost experts in learning theory, hasdiscovered that on average:

We Learn...

- 10% of what we read- 20% of what we hear- 30% of what we see- 50% of what we both see and hear- 70% of what is discussed with others- 80% of what we experience personally- 95% of what we TEACH someone else

Unit 3: The Instructional Role

The clinical instructor is active in both the academic and clinicalenvironments and must adjust to the special nature of each.Familiarity with both settings eases the transition to the educator role.

The Academic Setting

Teaching responsibilities and schedules are often quite different fromthose of her co-workers; therefore, the faculty member usually worksin isolation from her colleagues. Because the adjunct clinicalinstructor is rarely scheduled to be at the college, she is likely to misssocializing opportunities. In spite of demanding personal workschedules, there are numerous advantages for the part-timeinstructor to visit the nursing department on a day when most facultyare present and take advantage of networking, sharing of ideas, andemotional support. The clinical instructor can interface with full-timefaculty and develop a better working knowledge about the program.For the sake of course continuity, this is a good time to meet with thelead instructor as well as other adjunct clinical faculty who areteaching the same level course and to get a sense of how classes(didactic and clinical) are going. Although not required to attend,part-time faculty usually are welcome at department faculty meetings.Participating in these meeting gives the part-time faculty member asense of belonging to the faculty as a whole and provides someinsights into the issues that affect program functioning. (O'Connor,p.22)

As previously mentioned, much of the work of the clinical instructor isdone in isolation from other nursing faculty members. As anadvantage, the faculty member has full control in the clinicalexperience; but for important decision making matters, it is oftendifficult to locate a fellow faculty member. As a result, it is alwaysadvantageous in the clinical setting for the instructor to seek out otherfaculty members (from the same program or from another school)who are also present in the clinical setting during similar timeframes.Just knowing who else is teaching in the same facility at the sametime can be reassuring and supportive.

The Clinical Setting

The role of the clinical instructor is multifaceted. She must managethe clinical experience to achieve the curriculum and objectives of theeducational. Clinical teachers often function as diplomats andnegotiators with staff members while serving as gate keepers,buffers, and protectors of students. Positive liaisons are enhanced byestablishing and maintaining good working relationships and regularcommunication between instructor and staff members. (Gaberson,K.& Oermann, M, p. 36)

The instructor's ability to interact and communicate effectively withstudents, staff, and patients is an essential component of her successand the success of the clinical rotation. Mindful that her effectivenessas an instructor is influenced by the strengthen of the student-teacherrelationship, the instructor must maintain boundaries while promotingtrust and communicating caring. Social friendships with studentsmust be avoided in order to avoid role conflict and confusion.

A working knowledge of the clinical facility (physical layout andpersonnel) enhances the instructor's capability to manage the clinicalrotation. The teacher may become well-acquainted with a newclinical setting by working with or observing the staff for a few daysprior to entering the site with students. In addition a clinical agencymay require faculty members to attend an orientation program thatincludes introductions to agency staff, clarification of policiesconcerning student activities and review of skills and procedures(Gaberson,K. & Oermann, M, p. 37).

There are inevitable advantages and disadvantages for the clinicalinstructor who is teaching in a facility in which she was once or is nowemployed. When functioning as a teacher who is employed byanother agency, she is a guest in the facility. An instructor, who alsocontinues an employment relationship with the facility, must guardagainst inevitable role confusion, as may occur when the staff needsher while she is trying to teach (O'Connor, p. 24). The learningexperience of her students is her primary focus.

Advantages for the instructor who is or has been employed in the

same facility where she is presently responsible for student clinicalexperiences includes a familiarity with:

- staff (nursing, medical, ancillary workers) which easescollaborations necessary to enhance student learning (i.e.,patient assignments, off-unit experiences, post clinicalconferences)

- policies and procedures- medical administration systems- documentation

According to O'Connor (p.24), "Being a guest involves knowing andconforming to the operating policies and practices of the facility andthe clinical unit. The clinical instructor must learn to go with the flow,'and avoid criticizing staff or established routines. While the clinicalinstructor may need to explain discrepancies between staff practicesand the standards to which students are held, this needs to be donein terms of differences in approach, avoiding value judgments.Students need to know there is more than one 'right' way to do things,and that different nurses approach patient care in different ways."However, when a breach in practice has occurred, the instructor is toguide the student(s) through the chain of command and policypractices of the appropriate facility as well as those of the collegedepartment of nursing.

Assessment

Prior to entering the clinical setting, the instructor must assess eachstudent for level of relevant skill development as well as cognitive andaffective preparation. When learning complex skills, it is easier forstudents to practice first in a simulated setting away from thestressors of the actual practice setting. After ample skill practice timeand before gaining entrance to the clinical area, the student shouldbe tested for competency in newly acquired skills.

Student clinical assessment continues throughout the semester.Once the hospital rotation has commenced, a minimum of an interimand a final evaluation of individual student performance should beprovided. Each week, summative reports, based on anecdotal notesof clinical accomplishments, are to be reviewed with each student.

Records should be kept for every student and should include bothpositive and negative examples of behavior. Anecdotal recordsprovide essential objective data that will contribute to the finalevaluation. (Course syllabus contains content -specific objectives;Appendix B contains a sample course specific evaluation form withlevel and behavioral/technical objectives; Appendix B also containsAnecdotal Note forms).

Course Continuity

For course continuity, the lead teacher (often the full-time theoryinstructor) should meet with the adjunct instructor(s) prior tobeginning the clinical rotation to review and explain the followingdocuments and resources necessary to guide clinical teaching:

1. Program objectives, and the level objectives that contribute totheir achievement

2. Conceptual framework of the program3. Course syllabus4. Course materials given to students, including the schedule of

clinical experiences5. A copy of any text being used for the course6. Calendar indicating school holidays and breaks as well as a

breakdown of student schedules away from the clinical unit7. Room assignments for pre and post clinical conferences8. Copy of rotation schedule and clinical objectives for each unit9. Letter for Nursing Education Department Nurse Manager

verifying student CPR, malpractice insurance, andimmunizations

10. Student evaluation forms and timeframes11. Systems of medication administration (Pyxis machines),

documentation, and information retrieval.

Unit 4: Preparing the Clinical Setting

Clinical nursing can be described as a "team sport". Team membersinclude the nursing program faculty and support staff, clinical staffand liaison support personnel, and the students. The mostsuccessful clinical experiences do not usually just happen but are theresult of the teacher's knowledge of and collaboration efforts with theinvolved team subgroup(s). One of a clinical instructor's greatesttasks is creating a "safety net" environment for students so that theymight develop confidence in their emerging competencies. Thebetter the interfacing with the various members of her team, the moreaccepting staff will be to their interactions with students.

Clinical Staff

Groundwork in preparing the clinical agency staff for a clinical rotationusually begins with the teacher's initial contact with the agency. Solidworking relationship with the nursing staff often results in importantbenefits for the students. Therefore, communications between facultyand facility staff are vitally important. Approximately, 6 to 8 weeksbefore the first clinical day, letters should be written to the facilityliaison person and unit managers to alert staff to the beginning of anew clinical rotation. Included in the letter are the dates and times ofthe rotation, units the students will be assigned to, and skill level ofthe students. So that staff members might fully participate in theinstruction of learners, the roles of teacher, students, and staffmembers should be defined. (See Appendix C for Clinical LearningActivities for Teacher, Students, Staff ; for Check-Off List forInstructor Initiating a Clinical Rotation; and for Letter Alerting FacilityLiaison Person and Unit Managers to Start of New Clinical Group.).

Additionally, when entering the facility at the very beginning of clinicalexperience, the lead instructor or part-time clinical instructor mustprovide the facility liaison person with:

1. Her name and phone number2. Student list of names3. Clinical learning activities for teacher, student, staff4. Clinical learning objectives

5. Clinical schedule6. Level of the student

So that the members of a nursing unit might be adequately readied tohelp students identify and work through advantageous learningexperiences, each nurse manager on whose units the students areassigned must be given a student clinical schedule, a list of instructorand student names, and course clinical objectives. Staff membersalso need to be aware of specific learning objectives as well as thelevel of the learner. Staff need to know which patients have beenselected for student assignments, and in which activities students willbe involved. It's critical that they know about students' responsibilityfor administering medication and for completing documentation oncare activities. (See Appendix C for Student/Staff DailyCommunication Sheet). When properly informed about studentlearning needs, many nursing staff enjoy assisting with patientassignment selection by providing input about which clients mightbest enable students to meet objectives as well as those that shouldbe avoided if possible. In turn, staff expect that changes in a patient'scondition be reported promptly to the appropriate staff member.

Unit staff need to be informed of expectations concerning their role inevaluating student performance. Clinical staff need to trust that theinstructor will remain open to criticisms and suggestions about thecourse of the clinical experience and the performance of individualstudents. The instructor can invite such feedback, both positive andnegative, by asking staff if there is anything about which the instructorshould be aware or by simply asking how the day went after studentshave left the clinical area.

The Student/Staff Communication Sheet is an alternative vehicle forreporting student performance. When problems are identified, theinstructor should deal with these and then report back to staff that theproblem has been addressed. (O'Connor, p.56) Although staffmember feedback is valuable in formative evaluation the teacher isalways responsible for summative evaluation of learner performance.

Because awareness of problems involving students sometimessurface in the clinical setting after the clinical group and instructorleave the facility, staff also need to know whom to contact at the

college. The instructor provides key staff, i.e., facility liaison personand unit manager, with the names and phone numbers of theprogram director, secretary, and herself.

In this era of high patient census and acuity, working with students tocomplete patient care can be extremely time consuming and stressfulfor busy staff. Whenever possible, students must exhibit awillingness to help staff when help is needed to provide quality patientcare. Reciprocating for the accommodations staff make in helpingstudents is a must and contributes to a sense of a team effort.

The Student Group

To help students "settle in" to a new clinical site the instructor mustprovide the members of the clinical group with information about thelearning objectives; the clinical agency; the roles of teacher, student,and staff member; rotation schedules; and maps to facilities utilizedfor the rotation.

Students want to be as independent as possible, but also want thefaculty member accessible and supportive in helping them to findcritical information, collect clues, figure out how to put assessmentdata together, develop appropriate nursing action, and evaluateresults. They are aware that they will need to be corrected as theylearn, but expect that corrective criticism will take the form of alearning experience rather than a embarrassing encounter.

O'Connor (p.59) describes how to set a "safe" environment forparticipative learning:

"Learning becomes exciting and goal achievement possiblewhen students are valued participants in the learning effort. Give students the freedom to learn bydoing. Set high (but reachable)standards coupled with an expectation that students can andwill meet them ("you can do this!").

Engage in collaborative problem solving with students as theystruggle with the day's assignment.

Provide constructive criticism that includes comments onpositive as well as negative behaviors and is phrased to buildstudents' confidence in their potential to succeed. Whenstudents can trust that the instructor will not reprimand them inpublic they lose the fear of being humiliated in front of staff,peers, and patients and become more accepting of correctivefeedback."

Before the Clinical Experience Begins

If at all possible, plan to meet with the clinical group the day beforeorientation to the health care facility. Meeting the clinical instructor,even for a few minutes, in the campus setting strengthens theinstructor's connection with the program and the group (See Video:Student Orientation). The initial meeting should be used forintroductions and for providing necessary information related to theclinical setting, such as:

- Written directions to the facility including a map- Safety issues, reminder to leave valuables at home- Type of dress to be worn (uniform lab coat, street clothes, name

tag)- Equipment (stethoscope, scissors)- Small notebook and pen- Provision for essential communications- Items that might interfere with student's activities --cell phones

and pagers--should be left at home- Instructor's pager number to be used for 1) in-hospital

communications between students and instructor or 2) essentialcommunications between students and their family members

The instructor, on the other hand, needs information about eachstudent's previous clinical experiences as well as knowledge ofindividual expectations and goals for this experience. Such data isused as a backdrop for developing clinical learning activities. Eitherby meeting with each student or eliciting necessary data from formerteachers, the current clinical instructor should identify skills orexperiences the student would like to acquire in this rotation.

The First Clinical Day

Often the nurse manager of the staff education department serves asliaison to the instructor and is responsible for arranging the details ofthe student orientation to the health care facility and providingresources for the program. Frequently the instructor is accountablefor the actual presentation. Ideally, the lead instructor should beavailable to conduct the first orientation for the new instructor with theadjunct faculty in attendance. The lead instructor could possibly becompensated in flex time or comparable time in clinical unitsdeducted from her teaching load. From that occasion on, subsequentorientations could then be organized by the new instructor. Facilityorientation information includes:

- Institutional philosophy and mission- Organizational structure and key personnel- Fire, safety, and biohazard policies and procedures- Patient Rights- Operation of a computerized information system- System for charging supplies- Postclinical conference rooms -- locations, dates, times- Tour of nursing units, including:- Introduction to nurse managers and key staff members- Examination of nursing care plans, the Kardex, and patient chart

(to gain a sense of how these documents are organized andwhere information they will need in preparing for futureassignments is located)

- Explanation of daily shift routines- Demonstration of operation of patient room equipment including:

bed controls, call bell-intercom system, oxygen outlet, televisioncontrol

- Location of Nursing Unit Standards as well as Policy andProcedure Binders

The initial meeting with students in the clinical setting sets the tonefor the experience and provides the structure within which clinicallearning will occur. The following learning expectations are bestpresented as professional role behaviors observed by all nurses intheir practice:

- Instructor's modus operandi:- Documentation practices, approved abbreviation list, and review

of sample patient chart- Medication administration policies and procedures of facility- College Nursing Department's Medication Administration

Requirements (See Appendix C)- Math Proficiency Test and passing grade requirement to enter

clinical area (See Appendix C)- Clinical Evaluation Forms --to each student with a detailed review

of criteria for passing and failing and timeframes- Review of Needs Improvement Form, Educational Agreement,

and Policy and Procedure of Remediation- Review of and expectations of Long or Abbreviated Nursing Care

Plans- Confidentiality (Appendix C, Confidentiality Forms)- Absent days and make up assignments for absent days

(Appendix C Make Up Assignments)- Written assignments , i.e., nursing care plans or clinical concept

maps: due dates, criteria for evaluation, turn-around time forassignments

- Feedback, anecdotal notes (see Appendix B)- Student responsibilities regarding preparation for every clinical

learning session through reading and interviewing patients

Orientation is also an opportune time for the instructor to emphasizeto students that while it is impossible for any nurse to knoweverything; the privilege of caring for individuals includes theresponsibility of researching answers to questions that ariseregarding patient care rather than guessing. . . a practice which is

unsafe and dangerous.

O'Connor (p.19) also adds, "The instructor needs to provideexamples of unsafe performance, stressing that making errors is partof learning but failing to recognize, report, and correct those errorscan have dire consequences for patient safety and will result in aclinical failure. Communicating the instructor's interpretation of whatconstitutes a satisfactory performance alerts everyone to theinstructor's standards."

Students almost always perceive the first day of clinical learningactivities in a new setting as stressful. Clinical teachers should planspecific activities for the first day that will allow learners to becomefamiliar with and comfortable in the clinic environment and at thesame time alleviate their anxiety. These activities include tours,conferences, and special assignments. A scavenger hunt thatrequires pairs of students to seek out equipment and suppliesreinforces the orientation to the physical plan of the unit. Suggestedstudent clinical agendas for orientation through clinical day #2 as wellas a list of items that might be included in a scavenger hunt appear inAppendix C. More advanced students who have some familiarity withthe clinical setting may be given a patient assignment on the first dayof their clinical rotation in "tandem" with a staff nurse as a means ofintroducing students to the clinical environment.

Handouts should be provided that review all relevant informationbecause students may be overwhelmed by the orientation and unableto sort out the essential from the "nice to know." Many nursingprogram faculty collate all necessary data and supply students with ahospital-specific clinical binder.

Unit 5: The College LaboratorySetting

In addition to technical skills practice before entering the clinical area,a well designed laboratory may serve multiple functions as a learningresource center. The instructor can be very creative in developing orutilizing programs to strengthen decision making, communicationtechniques, problem-solving strategies, and documentationproficiency. To maximize student use of this potentially powerfulresource, learning laboratories should be open during a wide range ofhours to meet individual needs, including, if feasible, evenings andweekends when students are less likely to be in class or clinical area.

Instructional Materials and Alternative Methods ofDelivery

Learning laboratories commonly are used for psychomotor skilldemonstration and return demonstration. Demonstrations may be liveor recorded. If the demonstration is recorded each learner can viewthe performance at a convenient time and repeat it as desired. Videotaping a student's evaluation is an effective means for providingpositive feedback as well as clearly identifying areas needing furtherdevelopment. Skills checklists can be used as guidelines for practiceand evaluation.

Skills instruction is enhanced through the use of available written andmediated materials. Many clinical objectives and competencies maybe met by the students themselves through self-directed learningactivities. Whether planned by the teacher as part of the clinicalactivities or recommended to meet specific learning needs, self-directed activities are intended for completion by students on theirown. Mediated materials that depict various nursing skills or casestudies include filmstrips, videos, computer-assisted or computer-interactive programs, CD- ROM, and the Internet. Technologymediated instruction facilitates learning by offering additionalinstructional delivery tools and strategies which:

- complement new skills being introduced by faculty

- simulate clinical equipment too costly for the nursing departmentto purchase, i.e. PCA pumps, IV pumps

- depict patient care scenarios to help students understand howconcepts and theories are used in practice and give them anidea of what a clinical situation is like

- promote development of problem-solving, decision-making, andcritical thinking skills

- enhance the interactions between the student and the faculty.

To assist student learning, the instructor must identify objectives to beachieved through completion of the multimedia. Questions should bedeveloped for students to answer as they progress through themultimedia and at the end of instruction. Also a multimediaevaluation form is given to the student to evaluate the program usedin terms of quality from a learner's perspective, and usefulness indeveloping knowledge and skills for clinical practice (See Appendix Dfor Multimedia Evaluation Form).

Technology has fundamentally and irrevocably changed life. Thisnew concept in education shifts the focus from teaching to learning.The instructor is viewed as a guide to information rather than a vesselfiller. Students assume a more active role away from their traditionalpassive roles as receptacles for information supplied by professors.Technology mediated instruction is a major vehicle for transition toincreased participatory, active learning. Technology providesstudents with individualized activities that accommodate differencesin students’ levels of preparation, pace of assimilating information,and learning styles. Lastly, as students prepare to enter nursing, a"team sport," multidisciplinary learning (where students are working ingroups of twos or threes) engages learners in interactivecollaborations.

Structuring the Laboratory Experience

Because several classes of students frequently vie for use of thecollege laboratory, reserving a room or rooms for a group of studentscan be frustrating. In order to maximize time and utilization of thecampus laboratory setting, students should be informed of theirresponsibility to review the designated skills prior to collegelaboratory sessions

When students have read in advance or viewed the mediatedmaterial, the instructor can immediately demonstrate critical elementsof the skill using a student volunteer or mannequin. While performingthe skill and with focus on the rationale for various aspects of theactivity, the instructor often shares aspects of a technique that areless noticeable on the film as well as "helpful hints of the trade" thatshe has learned in actual practice. At the conclusion of thedemonstration, students then practice the skill under the guidance ofthe teacher or assistant, either on their own or in pairs. Because theyhave come to class prepared, students have substituted increasedpractice time for time that would have been spent watching a film orvideo. The instructor has more opportunity to facilitate individualizedstudent learning by observing performance, offering suggestions andcorrections, and answering questions

The instructor, with a large number of students but a limited amountof time to assess for performance of the newly learned skill, will needsome assistance to test for competency. The aid can come fromgroup members. Once a student has successfully accomplished theskill she can then help her peers as they practice the procedure. Infact, each student who successfully demonstrates the skill to theinstructor can be empowered to both teach and evaluate otherstudents. Spot checks of student technique by the instructor ensurethat peer teachers are maintaining standards.

Another option of students collaborating with one another is to havethem pair up and practice the skill together. Each learner takes a turnat portraying the role of the nurse and of the patient. An additionaladvantage from such a role playing is the "student patient" becomesaware of what the procedure feels like from the receiving end.

Memorization and regurgitation of "book learning" is not enough tomake a student a good nurse. The key is application. For students,learning to "think on your feet" means being able to apply quicklywhat they know in practical, everyday situations. The rapid and sounddecision making that is essential to good nursing requires years ofexperience and repetition. The practice of good critical thinking leadsto good thinking in clinical area. The instructor can stimulate problemsolving thinking, by asking "why" and "what if" questions from theonset, even while teaching the most basic of nursing skills. Becausestudents need more than one opportunity to perform skills, theinstructor should build some time for skill review into lab sessions.Stations can be set up within the lab, each with a brief realistic writtenscenario that directs the student to perform a skill. Competencytesting can also follow the same format. The following is an exampleof a scenario combining decision making proficiency as well as skillstesting:

Joanie has just received a new client on her unit who is toreceive 1 unit of RBCs within the next hour. The client has 500cc D5LR infusing. What nursing actions are necessary beforeadministering blood?

Prepare the infusion line as if you were to administer blood.

Within 30 minutes after starting the RBCs the client begins tocomplain of feeling warm.

You take her vital signs and note a slight elevation oftemperature. Tell me what your next implementations will be.

Five hours after you have initiated to flow of blood, the infusioncontinues to slowly drip.What will your actions be at this time?

The "campus clinical" is a realistic, risk-free learning mode enablingstudents to practice psychomotor and interpersonal skills. Accordingto Corder, the "campus clinical" is a way to enable students topractice skills they have learned in a semester, whether or not theopportunity to perform the skill has occurred in the clinical setting.One group of students is trained to "present" with history, symptoms,

and demonstrate physical manifestations of illness. A second groupof students, the "nurses", then complete assigned tasks, includingnecessary communications, observations, assessments, and recordtheir actions in the patients' charts. At the conclusion of the day, apostconference debriefs both "nurses" and "patients''.

Role-playing games can be used in which the learner portrays acertain role as a way of experiencing that role. O'Connor (p.77)describes one game intended to stimulate sensory and motor deficitsexperienced by the elderly. A series of props to feign commonproblems are used: magnifying glasses that have been clouded tocreate "cataracts," cotton plugs for ears to simulate hearing problems,and gloves to decrease tactile sensations. Once the props areapplied, students are encouraged to perform simple tasks, likeopening a medication bottle.

Research on the utility of the college laboratory in nursing educationsuggests that preclinical testing of skills is "an effective strategy forreducing anxiety related to initial transfer of skill learning from alaboratory to a clinical setting and enhancing self-confidence" (Bell).When feasible, consider scheduling competency testing in thelaboratory setting of the same hospital students will be experiencingclinical rotations. A major advantage is the availability of costlyhospital-specific equipment, i.e., IV pumps, PCA pumps, chest tubesets. While clinical skills evaluation is an effective tool at thebeginning of a semester to assess student readiness to enter a moreadvanced semester, competency testing may also be completedmidway or at the end of the semester to note student progress. SeeAppendix D for an example of a competency testing evaluation form.

Unit 6: The Clinical Practice Setting

Most students and instructors have at least some anxieties andexpectations prior to beginning a new clinical rotation. Preparation ofstudents for the clinical area is critical for promoting confidence withinthe group and positive attitudes about learning. Under the guidanceof the instructor, disconcerting concerns and fears are disclosed andexpectations revealed.

Expectations, Hopes, and Fears

A great exercise involves each student identifying her expectations,hopes, and fears on three separate yellow "sticky" notes. Theinstructor divides a white board or flip chart into three separatecolumns -- expectations, hopes, and fears -- and then directs eachstudent to post her "sticky sheet in the correlating column. Eachstudent or the faculty member then verbally reviews the concernsand, jointly, the group examines solutions (See Video: StudentOrientation). Depending on the level of the student group, studentscan reveal such perceived proficiency deficits as in documentation,medication administration, skills performed, or management skills.With the information she has acquired, the instructor now has theopportunity to "tailor-make" learning activities for each student'slearning experiences. The instructor can also utilize the data inplanning postclinical sessions. The revisiting of student concerns inpostclinical conference provides a wonderful opportunity to "check-in"on progress being made on various issues and provides validation ofstudent input.

Selecting Clinical Learning Experiences

The clinical setting is an environment rich in opportunities forlearning. Clinical assignments should be selected according tocriteria such as course learning objectives, needs of patients,availability and variety of learning opportunities in the clinicalenvironment, and the needs, interests, and abilities of learners (Reilly& Oermann; Stokes). While it is the teacher's responsibility tooversee the selection of learning activities, learners are encouragedto participate in selecting their own assignments.

Equally important to selecting clinical learning experiences ismotivating performance. Enthusiasm in patient care activities can beencouraged by an explanation as to why the activity is important, andby the passion displayed by the instructor for her work and to nursingin general.

A variety of back up plans are necessary so that on each assignedclinical day the student has the possibility of being exposed to qualitylearning opportunities. The following activities can be used asalternative approaches to clinical learning experiences when originalplans for student assignments go awry.

- Health teaching, knowledge base, and skills are enhanced whena student works along with the facility's recuperative therapist.

- Lung sound assessment skills can be fine-tuned by assigning astudent to a respiratory therapist to listen to the breathingpatterns of a variety of patients.

- Students can be paired in completing assignments when theacuity level of patients is unusually high.

- Critical thinking skills can be honed when a learner is designatedas a "star" student and accompanies the instructor duringstudent rounds. Assessment, decision making, and problemsolving are integrated as the instructor assists each student inprocessing patient care information.

- Multimedia programs in the nursing department's campusresource center may be assigned .

- Case studies can be developed for review to reinforce theapplication of theory to practice

Techniques to Help Students Prepare for ClinicalLearning

Written assignment, such as nursing care plans and concept maps,improve problem-solving and critical thinking skills and are examplesof techniques which help students organize for the clinical day. Muchlike Sherlock Holmes solving a mystery, a student who is completingthe paperwork must review relevant theoretical information as well aspertinent clinical assessment data and follow procedural guidelines.

The student is expected to provide rationale for findings and plannedactivities. The instructor's evaluation of the assignments is forfeedback purposes to enhance learning rather than for gradingpurposes. On the other hand, summative evaluation of completenessof all writing assignments can be included in the student clinicalevaluation form at mid-semester or at the end of the semester as apass or a fail grade. See Appendix E for an example of a nursingcare plan.

Because students benefit best when feedback immediately followsbehavior, the sooner written assignments are corrected by theteacher and returned, the better. Unfortunately correcting nursingcare plans is time consuming. "Turnaround” time frequently isdelayed and the student does not have access to the corrected formuntil long after the clinical experience is concluded. Too much timehas elapsed for the work to be a relevant source of learning. Toexpedite the process, the instructor might attempt to "spot check"nursing care plans during the pre-clinical conference time.

Clinical concept mapping is a visual learning tool that organizespieces of knowledge, showing relationships where they exist. The"mind maps" are graphic organizers that help learners to envision theflow that exists between a patient's diagnosis(s), clinicalmanifestations, therapeutic implementations, and anyinterrelationships (for example, an intervention used to treat oneclinical manifestation having a positive or a negative impact onanother ). As compared to nursing care plans, concept mapping hasmultiple advantages including:

- Students see connections of concepts and therefore betterunderstand them

- Concise format with all work displayed on one sheet of paper vs.the lengthy linear format of the nursing care plan

- Concept maps are easier and faster to evaluate and grade

For an example of how to implement concept maps in the clinicalsetting, see Appendix H.

The preconference is intended to prepare both students andinstructor for the clinical experience. It is extremely helpfully for the

instructor to arrive at the clinical site one-half hour to forty fiveminutes before the students' designated starting time. This additionaltime frame allows the instructor to quickly update changes in patientstatus and orders from the previous day. The instructor may use thepreconference to check on each student's preparation, instructstudents further, advise of any changes in patient conditions orinterventions, and, if necessary, fill in any deficits in student learning.Lower level students usually process information slower and areslower to organize their work day, therefore, this action is particularlyhelpful. Preclinical conferences may be conducted on a one-to-onebasis with students or as a clinical groups. In spite of its advantages,some instructors find that having students attend the change-of-shiftreport serves as a worthwhile substitute for the preconference (SeeVideo: Hospital Communication).

Another method used by instructors to confirm that a student is readyto begin her clinical assignment and/or is organized and managingher workload appropriately is to spot check each student periodicallythroughout the day, and discuss with the student her plans andrationale for patient care.

Guiding Student Learning in the Clinical Setting

Of the various attributes necessary for the instructor who wishes toguide student learning in the clinical area, two overriding skills areessential. The first is the ability to objectively observe theperformances of students engaged in clinical activities. Unbiasedassessment allows the teacher to identify areas of learning in need offurther development and to determine specific interventions ofremediation. Guidelines for observing students are:

- Examine own values, attitudes, and biases that may influenceobservations

- Document a series of observations over time before drawingconclusions

- Focus observations on the clinical objectives, competencies, orthe student's individual goals

- Discuss observations with students, obtain their perceptions ofperformance, and be willing to modify judgments when adifferent perspective is offered (Oermann & Gaberson)

The second competency essential in guiding learning activities isability to ask thought-provoking questions without interrogation.Open-ended questions are an effective tool used to guide or exploreclinically relevant thought processes and rationale used for arriving atclinical decisions. Questions can be asked to assess understandingof pertinent concepts and theories and their use in clinical practice,such as in identifying the correlation between a patient's diagnosis,relevant assessments, lab work, and medication. For examples ofquestions which raise issues for students to consider, requireanalytical thinking, and promote critical thinking, see Appendix E aswell as Video: Sorcratic Questioning). The way in which questionsare asked is significant; remembering all the while that the purpose ofthe query is to promote critical thinking, not to drill the student.

Managing Off-Unit Experiences

Assignments away from the clinical unit are frequently used toenhance the student's awareness of the clinical specialty the studentsare currently experiencing. The goals of clinical learning may be metin any environment where students can interact with patients.Educating nursing students in such settings has the advantage ofsensitizing them to a greater scope of nursing roles, as well as, to theneeds of diverse populations. Successful transition to the off-unitexperience requires student preparation. The instructor must providethe students with guidelines, specific clinical objectives, andassignments which link the care being provided in the associatedclinical with classroom theory.

Because off-unit experiences are usually outside the control of theclinical instructor, provisos must be made for the student to validateher experiences. A report may be in writing, as in completing anobservational guide or research questioner that asks the student toidentify pertinent data related to the off-unit rotation. An oralpresentation made to other members of the clinical group is anotherviable option. Oral reports have the advantage of educating allmembers of the clinical group to the learning activities and servicesavailable at any one off-unit service. While written or oral reportformats allow the instructor a "snapshot" of the student's learning inthe planned activity, the clinical instructor must also communicate

periodically with the off-unit staff to validate the level of studentperformance and behaviors as well as to authenticate the continuedappropriateness of the clinical rotation. Spot checks can beaccomplished by phone calls and/or on site visits.

Taking Advantage of Serendipitous Opportunities

When a clinical situation occurs that provides an excellent opportunityfor teaching a concept, demonstrating a technique, or discussing anethical issue, this opportunity should be seized without concern abouthow it "fits" with the day's clinical objectives or even the overallcourse objectives. Additionally, clinical instructor should remain alertto those community events that provide opportunities to learn moreabout aspects of the role of the professional nurse. (O'Connor, p.114) For instance, group participation in health fairs sponsored bylocal governments, schools, or senior centers can promote thedevelopment of interprofessional interactions, health teaching andadvocacy.

The Clinical Postconference

Postclincal conferences, held at the end of clinical day, provide anadditional opportunity for fostering student learning. Clinical activitiescan be discussed and clinical situations analyzed. Postclinicalconferences are also a favorable time for the instructor to promotethe development of leadership skills in nursing students. As facilitatorof the sessions, the instructor can acquaint students to the skills ofcontributing input as well as feedback, critiquing each other's work,and expressing feelings about the events of the day. The postclinicaldiscussions are NOT, however, intended as substitutes for classroominstruction; the teacher cannot lecture nor present new content tostudents. Instructors utilize the following activities to expedite activeinvolvement of each student:

- Ask questions, suggest ideas, and present leading statements- Provide nonthreatening feedback- Assign students to present an oral review of medications specific

to course objectives or current nursing specialty- Delegate student(s) to an oral presentation of a particularly

interesting actual or potential case study focusing on subject

matter currently being studied in the didactic portion of theclass. Instructor can facilitate with Socratic question to assistin linking theoretical concepts to care giving, i.e., diagnosis tomedications, lab work, and assessments.

- Collaboratively analyze NCLEX-type review questions coveringcontent currently being studied in lecture to ascertain as to whythe correct answer is, clinically, the most significantly sound.

Because conference rooms are in such high use, scheduling a roomfor the activity is a necessity and must be done well in advance of thebeginning of the clinical rotation. Generally, the lead instructor makesnecessary accommodations. However the adjunct faculty membercannot assume this to be the case and must, therefore, confirm withthe lead instructor that postclinical rooms have been reserved. Thestaff development officer is often the school liaison person and, mostlikely, the individual to contact for room scheduling. A list of datesand times for postclinical conferences will need to be submitted.

Interpersonal Issues

Providing corrective feedback (on nursing care plans, formativeevaluations) is an important dimension of laboratory education. Theintent of constructive feedback is to help the student keep herbehavior on target and achieve her goals. When providing feedbackon student activities, focus on the behavior the student can changeand its effects on patient care. Feedback should be specific ratherthan general. Corrective feedback needs to be returned in a timelymanner so the student knows she is or is not on the right track,therefore, it should be given as soon as possible after the event hasoccurred. Describe what is wrong, why it is wrong, and how it can becorrected. Conversely, praise a positive performance and suggestany improvements, if needed (See Video: Interpersonal Issues inClinical Education.

On the occasion when a student must be disciplined do soimmediately after removing her to an isolated area to provide privacy.In a matter-of-fact manner, focus on the problematic behavior andany prior instance of the same or similar behavior. Assist the studentto explore avenues to remediate the situation. Outline theconsequences of continued episodes of similar behavior and the

rationale for these. Provide a written warning to the student todocument the event and place a copy of the memo in the student'sfile (See Appendix G for Needs Improvement/Learning ExperiencePlan)

There are as many different ways as reasons for removing a studentfrom the clinical area. The student who is totally unprepared for theclinical experience is better sent to the library for an hour to do thenecessary preparation than sent home for the day. However, thestudent who arrives in the clinical area unwell, under the influence ofdrugs or alcohol, or emotionally unstable poses a potential risk topatients, herself, or others in the clinical setting. The instructor mustquickly evaluate the situation in terms of the possible hazards itpresents and remove the student from the setting if necessary. It isimportant to check in advance what the college's Nursing Departmentdefines as its policy in removing disturbed students from the hospital.When a student must be removed from the clinical area, notify staffthat the student is leaving and discuss plans to cover her assignment.As soon as possible, report the incident to the school contact.Acknowledge to others in the group that the student has left for theday. After the clinical experience is over, attempt to determine whathappened after the student left the clinical site.

Unit 7: Instructional Skills for theClinical Practice Setting

Student nurses tend to gauge their "being a real nurse" by the sumand diversity of technical skills they have performed. In theireagerness to accomplish as many procedures as possible, studentssometimes fail to prepare adequately.

Supervision of Student Performance of TechnicalSkills

The new instructor must be aware of potential pitfalls that may occurin any stage of skill development and take actions to "set the scene"for a positive learning experience (See Video: Supervising StudentPerformance). To ease the process for skill mastery, the clinicalinstructor can do the following:

- When paged by a student seeking permission to perform atechnical skill, make the following inquires:

- Has the student performed the procedure in the past? …inthe hospital? …with success?

- At what time is the procedure to be performed?- Does the student need to review the critical

elements and does she have the specific clinical skill check-off list?

- Does the student have access to the procedure information specified by the nursing unit?

- Have the necessary supplies been gathered?- Has the patient been informed of the upcoming

procedure?

- Once the instructor has arrived on the nursing unit, review withthe student -- ideally, in a quiet area, free of distractions -- thevarious steps of the procedure.

- At the bedside, if possible, the instructor might consider standingnear at hand, but out of visual range of the patient, so that ifnecessary she may provide nonverbal assistance to the student.

The clinical instructor must acquire the ability to maintain an attentivepresence while the student performs a new skill and allow thestudent to complete the procedure unless there is an evident causeto take over. If the student is having some difficulty, the instructorcan facilitate by offering words of encouragement or clues as to nextsteps. Talking the patient through the procedure, as long as thelanguage used is comprehended by the patient and his family,diverts attention from the support the instructor is giving the student.Another technique for supporting a student in a new learningexperience is for a peer who proficiently performs the procedure orthe instructor to assume the role of assistant. The assistant can thenhelp the student by organizing equipment, demonstrating criticalelements, obtaining necessary supplies, or focusing on the needs ofthe patient.

The impact of a student being stripped of control of the patient caresituation includes diminution of self-confidence, humiliation, anddisruption of the patient-student relationship. In spite of thesenegative repercussions that are likely to result when the instructortakes over for the student, the clinical instructor must be prepared tointervene when the student's actions, inaction, or ineptitudejeopardize patient safety. The instructor should calmly andassertively intercede. For example, the instructor might say, "I'llfinish this packing this wound, Jill, while you prepare the followingdressings." The patient should be spared any alarm that somethingmight have gone wrong, the student should be spared anyhumiliation at having erred in her performance, but the situation mustbe addressed directly and promptly. The instructor should return theprocedure to the student for completion if it is safe to do so, andmust conduct a debriefing with the student after the patient's well-being has been assured and the student and instructor are awayfrom the patient's room(O'Connor, p. 129). (See Video: The StudentHaving Difficulty with a Procedure)

Another important strategy the instructor observes in studentperformance is time management; "how to get it all done" and "what

to do when." To effectively help students organize and prioritizeclient care activities see Appendix F for an example of workorganization schedules. Elements of patient care to be consideredwhen planning for the shift:

- Priority setting: patient care interventions, unit schedule,coordination of student learning activities

- Patient safety, comfort and privacy needs- Flexibility in planning routines (O'Connor, p.132)

Developing Critical Thinking Skills and ReflectivePractice

Critical thinking, along with communication and technical skills, is oneof the major educational program outcomes identified by educators.Critical thinking involves forming conclusions, making decisions,drawing inferences, and reflecting. Reflection is a process of thinkingback or recalling an event to discover the meaning and purpose ofthat occasion. As a nurse, reflection can involve thinking back on aclient situation or experience to explore the information, make senseout of the experience and incorporate the knowledge gained from theexperiences into her pattern of information processing. By learningfrom past experiences, the student:

- identifies links in concepts and theories that relate to care of herpatients

- reinforces positive learning that has occurred- identifies where further learning is needed- discusses feelings generated through the experience- examines changes that may be needed in her own behaviors to

better meet patient needs

Strategies the instructor can use for promoting critical thinking andreflective practice include:

- Socratic questioning (See Appendix E and Video: SocraticQuestioning for examples of Socratic questions.)

- Debriefing discussions (which can occur on a one-to-one basis

with the instructor or in the presence of peers during postclinicalconference) enable students to report on their clinical learningexperiences; reflect upon the patient care they provided; andshare their relevant feelings and perceptions. Feedback bypeers and the teacher can reinforce student actions or suggestalternate decisions and approaches

- Journaling. Rather than recording a diary of incidents, a clinicaljournal is an objective and subjective chronicle that reflects astudent's attitudes, feelings, and cognitive learning throughout aclinical experience. Writing journal entries assists a student nursein defining more clearly the meaning of any critical incidents.There are different ways of structuring journals. An exampleform for journals can be found in Appendix F.

Process Recordings are particularly effective in teaching therapeuticcommunications. Verbal as well as nonverbal interaction betweenthe student and client are recorded to be analyzed by the student forappropriateness of various communication strategies. The studentnext summarizes what she has learned from the exercise and howshe would modify her approach in future encounters with the same orother patients. An example of a process recording can be found inAppendix F.

Unit 8: Evaluation Strategies for theLaboratory and Clinical Setting

Another important function of clinical teaching is evaluation . Theultimate goal of evaluation is to determine whether or not the studentcan safely perform stated clinical course objectives. Depending onthe purpose of the evaluation, clinical competency testing can beidentified as formative or summative. Formative evaluation is an on-going process as the teacher continuously and unobtrusivelymonitors student progress in meeting the clinical objectives anddemonstrating competency in clinical practice. Formative evaluationis not intended for grading purposes, but is a basis for furtherinstruction. Summative evaluation takes place at the end of alearning period --- e.g., at the end of a period, a course, or a program-- to determine if the objectives have been met and the competenciesdeveloped. This type of clinical evaluation determines what has beenlearned rather that what can be learned.

Clarifying the Standards for Evaluation

Goals identify those critical elements students must perform, whilestandards describe a method for categorizing a performance as "metobjective", "needs improvement" or "failed". An on-going observationof student performance with written descriptions that depict each levelof potential student performance support the instructor's objectivity inapplying standards consistently. Consistency of performance plusgrowth throughout the clinical experience often serve as touchstonesfor performance evaluation (Orchard). As mentioned earlier, a copyof a course specific clinical performance evaluation form must bereviewed with each student at the beginning of a clinical rotation toclarify course expectations.

Reliability in the application of standards is facilitated by the use ofrating scales. Rating scales, however, are not without problems. Toenhance cohesiveness in the application of ratings in making gradingdecisions, adjunct instructor(s) must confer with the lead instructor .For instance, does a midsemester rating of "needs improvement"performance for any one of the objectives result in a failure in the

clinical component of the course, or must a majority of objectives berated at a low level to justify a clinical failure? Additionally, a "needsimprovement" performance might be acceptable at midsemester, butinadequate for a final grade. Lastly, certain objectives are imperativeto safe practice and may be identified with an asterisk. These areelements that must be present whenever a skill is performed.

Selecting and Applying Evaluation Methods

Because clinical objectives cover the spectrum of cognitive,psychomotor, and affective learning, several types of evaluation toolsmay be used to assess student achievement. The following are asampling of the many clinical evaluation methods from which tochoose:

Rating scales

Check-off lists

Anecdotal Notes are a narrative description of the observedbehaviors of a student and are a means by which data arerecorded for later evaluation. Both positive and negativebehaviors should be documented for subsequent use. The writtenevaluation provides feedback that is useful to students andsubstantiates the ratings. See Appendix B for an example of aduplicate sheet anecdotal note form developed to expedite therecord keeping process. . Because the instructor gives the firstsheet of the evaluation form to the student by the end of eachclinical week, the student is always appraised of her progress inthe clinical area. In essence the format functions as a weeklyformative evaluation. The second sheet is kept in the instructor'sprivate file.

External raters: Feedback of others into the observation of studentperformance may include:

Nursing staff who are interfacing with the student(s) in participatingclinical facilities, including off-unit rotations

A clinical instructor teaching in the same course who has had no

prior clinical exposure to the student -- This option is generallyemployed as a last resort when the student's performance isborderline or failing and the student is in danger of being droppedfrom the nursing program. The special assistance andobservations required by an instructor when a student's clinicalperformance is not meeting standards is time consuming andunfortunately deprives the other students in the group of theinstructor's presence or learning opportunities. To enhancelearning for both the student whose performance is in question aswell as for her peers, a second instructor can be used. Also, anexternal rater may be necessary when the clinical instructor isconcerned that the student's performance may be biasing theinstructor's ability to provide a fair evaluation. Either the studentjoins the second faculty member's clinical group and is given aregular assignment or the second instructor is brought into theclinical facility to assist the primary instructor. The assistantteacher is responsible for a "second" evaluation of the studentwhose performance is being questioned plus overseeing one ortwo students who are assigned patient care on that same unit.

Written assignments,i.e.,completeness of Nursing Care Plans,Concept Maps, Process Recordings.

Self-Evaluations of clinical performance reveal needs andexpectations that the instructor can use to address feedback andidentify areas in which the student might enhance herperformance.

Reporting Results

To validate a student's ratings on an evaluation form, the instructorshould include excerpts from her antidotal notes. Due processconcerns the rights of a student. As related to the evaluationprocess, due process refers to the right to receive feedback onperformance in a timely manner, especially if it fails to meetexpectations; and to be told the consequences of continued failure tomeet expectations (Halstead). Due process also encompassesproviding the opportunity for remediation and informing students ofestablished appeal policies.

Techniques to Assist with Managing theUnsatisfactory and/or Failing Student

When clinical performance deficits are detected, inform the student (awarning) verbally and in writing of the observed behaviors. Focus onthe student's deficiencies and include suggestions for resolving theproblem(s). Have the student sign a copy of the written warning andgive her a copy to review. Place the signed copy of the form in thestudent's file along a with a written synopsis of the meeting. To viewthe Needs Improvement/Learning Experience Plan form seeAppendix G.

Repeated evidence of unsatisfactory patient care results in thestudent entering a learning agreement with the instructor. Options forremediation are agreed upon and catalogued on the form. A follow-upmeeting is planned to re-evaluate the student's progress. SeeAppendix G for a copy of the Educational Agreement form.

When a student is failing from a course, a student-instructorconference must be held to plan appropriate recourse. Succinctdocumentation of the entire evaluation process (from the first incidentof faulty patient care) is vital to support a failing clinical grade.Discussions with the student who is not meeting expectations shouldoccur away from the clinical area, in private, and might also includethe lead or the team instructor. The student is given the opportunity toreview the accumulated record. The student is advised of her optionto include a support person in the meeting. The support personcannot speak nor take notes . To identify problems, use anecdotalnotes and classify deficient behaviors under broad headings thatrelate to course objectives. If remediation is an option, a learningagreement to remedy identified weaknesses should be developedcollaboratively with the student, and put in writing. (See Appendix Gfor example of Education Agreement). A dated, signed memosummarizing the content of the meeting should be placed in thestudent's file, along with a copy of the remediation plan. As theclinical experience progresses, the instructor should make note ofteaching strategies and feedback that were implemented in support ofremediation. A follow-up meeting is planned to re-evaluate thestudent's progress.

When the student fails the class, the possibility for petition to reenterthe program at a later time frame can be discussed. Inform thestudent of the grievance process if she wishes to dispute the grade.

When the patient care practices of a student are deemed unsafe, theremediation plan should involve experiences outside the clinical area,such as in the college laboratory or resource center. Before thestudent is permitted to return to the clinical setting, a safe level ofpractice must be documented.

Whenever developing a remediation plan, the instructor must becognizant of the effects of implementing the plan on her ability toprovide adequate instruction and supervision to other members of thegroup . Due process does not require that the instructor abandon allother responsibilities to provide instructional support for the failingstudent. Patient safety and care needs must also be considered(O'Connor, p.197).

As mentioned previously, the instructor must keep precisedocumentation on all evaluation methods to defend against potentialaccusations of discrimination. Such recordings substantiate thenecessity of actions taken as well as of extra supervision of the failingstudent in terms of patient safety.

Appendices

Please see the individual appendices located on the CD-ROM. Theoption to print these will be available.

Bibliography

Please see the Bibliography located on the CD-ROM. The option toprint this will be available.

CreditsProduced byRegional Health Occupations Resource CenterSierra College Nursing DepartmentComins Media ProductionsMargaret White RN, MSNLinda Zorn RD, MA

Written byKathy Kolster RN, MSN

Scenarios written byKathy Kolster RN, MSN

Scenario Clinical Nursing InstructorsDonna Archer RN, MSN, CSCarol Brookins RN, MSNMarlene Feldscher RN, MSN

Scenario Student NurseJanae Patja

Hospital Clinical InstructorLaura Lind RN, BSN

Roundtable Discussion ModeratorKathy Kolster RN, MSN

Roundtable Discussion ParticipantsDonna Archer RN, MSN, CSPatricia Bagley RN, BSNCarol Brookins RN, MSNMarlene Feldscher RN, MSNDana Johnson RN, MSNStephanie Nielsen RN, MSNNancy Price RN, MSNDiane Tonda RN, BSN

Videographer/EditorDan Comins

CD-ROM DeveloperDan Comins

Project Funded by RHORC

Appendix A Theoretical Approaches to

Instruction

Learning Style Preferences Form Suggested Aids for Learning Modalities

Learning Style Preference Form

1. I can remember more about a subject through listening than reading.2. I follow written directions better than oral directions.3. I need to re-read things I write down so that I can remember.4. I can write with a sharp pencil without breaking the point.5. I require explanation of diagrams, graphs or visual directions.6. I enjoy working with tools.7. I rely on graphs and charts to better understand a topic or subject.8. I like to have stories read to me.9. I remember best by writing things down several times.10. I can understand and follow directions on maps.11. I do better at academic subjects by listening to the teacher or tapes.12. I easily learn and enjoy sports such as skiing, tennis, roller skating, etc.13. I learn to spell better by repeating the letters out loud than by writing the word on

paper.14. I better understand news by reading about it in the paper than by listening to the

radio.15. I find dancing pleasurable (either as a participant or watching).16. I prefer to read a newspaper to myself rather than have it read to me.17. I learn spelling by first writing the word with my pencil on paper.18. I would rather listen to a teacher’s explanation than read about the same material

in a textbook.19. I understand something better if I can hold a model of it in my hands.20. I would rather read directions than have them read to me.21. I prefer listening to the news on the radio rather than reading about it in the

paper.22. I obtain information on an interesting subject by reading about it.23. I would rather be a participant in sports than an observer.24. I follow spoken direction better than written ones.

Some- Often times Seldom VIS AUD KIN 1. _____ _____ _____ 1 _____ 2. _____ _____ _____ 2 _____ 3. _____ _____ _____ 3 _____ 4. _____ _____ _____ 4 ____ 5. _____ _____ _____ 5 ____ 6. _____ _____ _____ 6 ____ 7. _____ _____ _____ 7 ____ 8. _____ _____ _____ 8 ____ 9. _____ _____ _____ 9 ____10. _____ _____ _____ 10 ____11. _____ _____ _____ 11 ____12. _____ _____ _____ 12 ____13. _____ _____ _____ 13 ____

14. _____ _____ _____ 14 ____

15. _____ _____ _____ 15 ____16. _____ _____ _____ 16 ____17. _____ _____ _____ 17 ____18. _____ _____ _____ 18 ____

19. _____ _____ _____ 19 ____20. _____ _____ _____ 20 ____21. _____ _____ _____ 21 ____

22. _____ _____ _____ 22 ____23. _____ _____ _____ 23 ____24. _____ _____ _____ 24 ____

LEARNING STYLE PREFERENCES FORM

Scoring Procedure

Point Value for AnswersOFTEN =5 Points

SOMETIMES =3 Points

SELDOM =1 Point

Place the point value for your answers on the line next to itscorresponding item number. Next, add the value to obtain yourpreference score under each heading.

VPS – Visual Preference Score

APS – Auditory Preference Score

KPS – Kinesthetic Preference Score

HOW TO USE THIS INFORMATION

Remember that your preference scores indicate relative strengthsand/or weaknesses. This form is to be used with other diagnostictools to help you determine some of the ways you are best able tolearn. Discuss your scores with someone who is qualified tointerpret them in order to make the best of the time and effort youhave invested.

SUGGESTED AIDS FOR LEARNING MODALITIES

Use these aids to sharpen your particular dominant learning modality or to strengthen aweaker one. Try to be aware of the different activities you do daily to help all three of yourmodalities.

VISUAL AUDITORY KINESTHETIC

use guided imageryform pictures in your mindtake notessee parts of wordsuse “cue” wordsuse notebooksuse color codesuse study cardsuse photographic pictureswatch TVwatch filmstripswatch moviesuse charts, graphsuse mapsdemonstratedraw/use drawingsuse exhibitswatch lips move in front of a mirroruse memories (acronyms, visual chains, mind maps, acoustics, hook-ups), refer to “Memory Chapter”

use tapeswatch TVlisten to musicspeak/listen to speakersmake up rhymes/poemsread aloudtalk to yourselfrepeat things orallyuse rhythmic soundshave discussionslisten carefullyuse oral directionssound out wordsuse theatersay words in syllablesuse memories (word links, rhymes, poems, lyrics), refer to “Memory Champter”

pace/walk as you studyphysically “do it”practice by repeated motionbreathe slowlyrole playexercisedancewritewrite on surfaces with fingertake notesassociate feelings with concept/informationwrite lists repeatedlystretch/move in chairwatch lips move in front of a mirroruse memories (word links, rhymes, poems, lyrics), refer to “Memory Chapter”

Appendix B The Instructional Role

Anecdotal Note Forms

Evaluation Tool Sample Letter to Nurse Manager

1

NURSING PROGRAM EVALUATION TOOL

Student: ______________________________ Instructor: __________________________Semester: ______________________________

S = Satisfactory (passing)NI = Needs Improvement (behavior is not at an acceptable level)U = Unsatisfactory (unsafe)N = not observed* = Critical element; must be met satisfactorily

MIDTERM FINALOBJECTIVES S NI U N S U N

I. COURSE OBJECTIVE: Utilizes the nursing process basedon Roy’s Adaptation Model to provide direct care to stableadult clients with well defined health problems.

A. Assessment

*1. Collects data on the condition and treatment ofassigned adult/elderly clients from secondary sources(chart, Kardex, medication rand, lab results, nursingcare plan), requiring less direction as the semesterprogresses.

*2. Completes all essential research and data collectionprior to beginning patient care. Discusses/validatesdata with instructor.

*3. Assess assigned adult/elderly clients’ immediateenvironment for safety, comfort, and convenience-requiring less assistance as semester progresses.

*4. Performs initial systematic physical assessments onassigned adult/elderly clients – with decreasingassistance as semester progresses.

5. Assesses the cultural influences on assigned clientsand their families.

*6. Performs ongoing and focused assessments onassigned adult/elderly clients as ordered or asdetermined necessary in consultation with instructor.

2

OBJECTIVES S NI U N S U N7. Asks the client relevant questions concerning their

present physical, psychosocial and intellectual statein order to obtain accurate assessment data.

*8. Reports and/or seeks validation of changes and/ordeviations from the norm promptly to instructor and/orappropriate staff members.

9. Records assessment data on NR10 AssessmentWorksheet and, after instructor’s approval, onclients’ records.

B. Nursing Diagnosis

*1. Identifies and interprets connections betweenassessment findings and client’s medical diagnosisand condition with instructor assistance.

2. Write a complete, accurate nursing diagnosisstatement including NANDA diagnosis (problem),etiology (influencing or associated factors), andclinical manifestations.

3. Distinguishes between urgent and non-urgentnursing diagnoses based on related assessment data,with decreasing instructor help as the semesterprogresses.

C. Planning

1. Identifies at least one concise, client-centered,measurable outcome for each nursing diagnosis.

*2. Identifies the nursing measures and proceduresthat are likely to help the client achieve theoutcomes.

3. Explains the rationale for nursing interventionsrequired by the clients.

*4. Researches all drugs, including IV fluids

*5. Organizes care for 1 to 2 adult/elderly clientsexperiencing common and/or remedialillnesses/stressors.

3

OBJECTIVES S NI U N S U N6. For clients with stable, non-critical conditions,

plans care reflecting a basic understanding of eachclients:a. illness, including pathophysiologyb. treatment, including medications and

diet/nutritional needs.c. age/developmental needsd. sociocultural background/preferences

7. Writes goals, objectives, and planned actions onNR10 Care Plan.

D. Implementation

1. Within 15 minutes of arriving on unit, checkskardex and medication record for orders orchanges.

*2. Checks with primary nursing immediately afterreport to clarify assignment.

*3. Implements care plans within the assigned clinicaltime period.

4. Within 15 minutes of beginning patient care,verifies IV solution, additives, rate and tubing forcorrectness and expiration date and time.

*5. Administers medications safely and correctly:a. Researches all drugs before administrationb. Uses 5 rights of medication administrationc. Uses 3 checksd. Provides related teaching

6. Under instructor supervision only, the student:a. Performs new procedures or infrequently

performed onesb. Gives injectable medicationsc. Hangs primary IV setsd. Signs out and gives controlled medications

7. Has a complete assessment documented for eachassigned patient by 8:30 a.m. daily.

*8. Maintains Universal (or Standard) precautionswhen carrying out nursing care.

4

OBJECTIVES S NI U N S U NE. Evaluation

1. Evaluates effectiveness of nursing actions andinterventions in relation to the established clientoutcomes, with assistance from the instructor.

2. Identifies need for modifying plan and does so,with assistance from instructor.

II. COURSE OBJECTIVE: Utilizes basic communicationskills to interact with stable adult clients and theirfamilies.

A. Communication with Clients

*1. Consistently interacts with clients and in a friendly,courteous, tactful, and caring manner.

2. Allows clients to verbally express their thoughts andfeelings.

*3. Conveys acceptance of client without judgement.

3. Informs clients accurately of normal routines andpractices in agency.

*5. Accurately explains procedures in a manner theclient can understand and encourages questions.

*6. Consistently maintains appropriate clientconfidentiality.

7. Takes developmental and sociocultural factors intoaccount when communicating with clients.

B. Communicating with Others

*1. Notifies the clinical unit and instructor of anticipatedabsences or delays in arrival by the time assignedclinical begins.

*2. Provides a clear, concise report on patient conditionand status to primary nurse at the conclusion of theclinical staff.

5

OBJECTIVES S NI U N S U N3. Reports observations, interventions, and outcomes to

physicians appropriately.

4. Communicates with peers (classmates) in a cooperativeand supportive manner.

*5. Reports to and obtains information from appropriatenursing staff as necessary.

C. Written Communication

*1. Completes clinical assignments and nursing careplans correctly and on time.

2. Completes all documentation according to agencypolicy - promptly, accurately, and legibly.

3. Records repeated types of data with little or noprompting or assistance as the semester progresses.

III. COURSE OBJECTIVE Identifies the obviouslearning needs of clients and applies basic principlesof teaching and learning to convey information toclients and/or family members.

1. Identifies specific personal experience, developmental,socioeconomic, and cultural factors that should beconsidered in teaching plan.

2. Answers assigned clients’ questions and conveysinformation when the situation is appropriate; conferswith instructor/staff to see that clients’ receive correctinformation.

3. Participates in previously established staff teachingplans for clients as determined with instructorand/or staff.

6

OBJECTIVES S NI U N S U N*4. Identifies the obvious knowledge deficits and

learning needs of clients concerning dailyhygiene/health practices and illness/treatmentregimen.

5. Completes at least one complete teaching plan for anadult/elderly client using NR10 criteria and implementsplan after discussion with instructor.

IV. COURSE OBJECTIVE: Functions as a member of thenursing team while caring for clients with stable or non-critical illnesses.

1. Acquaints self with roles and responsibilities ofnursing staff members on assigned units.

2. Identifies the job description of non-nursing healthteam members. (respiratory therapy, physicaltherapy, social worker, discharge planner, dietician)

*3. Behaves in a manner consistent with the standardsupheld by professional nursing practice today.

4. Uses beginning problem-solving and decisionmaking skills in managing direct basic care forassigned clients, with assistance from instructorand/or staff.

5. Confers with nursing staff with the goal of ensuringthat appropriate discharge planning/arrangements arecarried out.

V. COURSE OBJECTIVE: Carries out basic legal andethical practices while caring for stable adult clients with well-defined health problems.

*1. Notifies instructor upon arrival if unprepared for anyreason.

*2. Performs only those nursing measures and procedureswhich have been included in the course of study.

*3. Executes nursing measures safely; reports any error oromission promptly to instructor and/or appropriatestaff person.

*4. Seeks assistance from instructor/staff memberwhenever uncertain regarding client care needed.

7

OBJECTIVES

*5. Consults with instructor or staff nurse if clients refusesany nursing measure or procedure.

*6. Behaves in a professional manner with regard toactions, communications, attitudes and appearance.

*7. Provides care with respect for the human dignity anduniqueness of clients.

8. Ensures that the clients’ questions, concerns, and fearsare addressed by the appropriate health care provider.

*9.Adheres to Federal and agency regulations andpolicies concerning controlled substances.

*10. Maintains client confidentiality, discussing careonly with instructor, assigned staff members, or inclinical conferences.

VI. COURSE OBJECTIVE Meets his/her second semesterresponsibilities related to fulfillment of the college,program, and Board of Registered Nursing requirementsnecessary for eventual graduation and licensure.

*1. Completes written NR10 Nursing Care Plans on eachassigned client each week.

*2. Passes NR10 Medication/Dosage Test with a minimumgrade of 80%.

*3. Collaborates with the clinical instructors and staff toidentify and seek needed clinical learning experiences.

4. Collaborates with clinical instructors to evaluate ownprogress toward achieving clinical objectives.

5. Utilizes clinical objectives and his/her own personalobjectives to write a self-evaluation at midterm and atthe end of the course.

8

Number of lab days/hours absent: Midterm __________________ Final: ________________

Tardiness: Midterm: ________________________ Final: ________________________

MIDTERM Evaluation

Meeting Clinical Objectives _________ Needs Improvement __________ Not Met __________

Instructor’s Signature: _________________________________________ Date: _____________________

Student’s Signature: ___________________________________________ Date: _____________________(Student’s signature indicates he/she has read evaluation)

(See attached Student Self-Evaluation)

Instructor comments:

FINAL Evaluation

Clinical Objectives Met _________ Objectives Not Met __________

Instructor’s Signature: _________________________________________ Date: _____________________

Student’s Signature: ___________________________________________ Date: _____________________(Student’s signature indicates he/she has read evaluation)

(See attached Student Self-Evaluation)

Instructor comments:

7/99 msf/kkRevised 5/02 msfNR10evaltool

9

NR10 STUDENT SELF EVALUATION

Student ________________________________________ Date______________________

Midterm __________ Final _________

A. Areas of Strength (things I do well):

B. Areas/Objectives I need to work on:

NR10evaltool

Appendix C Preparing the Clinical Setting

Adjunct Faculty Check-Off List

Clinical Rotation Orientation Outlines Student and Staff Communication Form

Student Orientation Checklist Student Orientation Treasure Hunt Activity

Clinical Calculations Test Code of Ethics Form

Student Objectives for OrientationMedication Administration Requirements

Clinical Day Make-Up Form Computer Program Evaluation

Video Evaluation

SEIRRA COLLEGE NURSING DEPARTMENTCHECK-OFF LIST FOR ADJUNCT FACULTY --CLINICAL

TASK TARGETDATE

DONEDATE

Obtain Nursing Department Part Time Instructor Information Guide fromDirector of Nursing Department, complete the employee check-in list andsubmit form to the Personnel Department. Read the handbook.

At least 6weeks before1st clinical day

Obtain Associate Degree Nursing Program Faculty Policy/ProcedureManual from Director of Nursing. Become familiar with nursingdepartment philosophy and protocol by reviewing context of theguidebook

At least 6weeks before1st clinical day

Meet with Director of the Nursing Program to initiate Board ofRegistered Nursing approval process for sanction as a clinical instructor.Submit a current copy of your RN license and CPR card.

At least 6weeks before1st clinical day

Meet with Director of the Nursing Program for self-study module,Strategies in Teaching Clinical Nursing.

At least 6weeks before1st clinical day

Meet with lead instructor to review and explain:1. Her goals and expectations

At least 2-3weeks before1st clinical day

2. Conceptual framework of the program3. Course syllabus4. Program objectives, and the level objectives that contribute to

their achievement5. Continuity between course theory and clinical activities of all

clinical groups at the same level6. Course materials given to students, including the schedule of

clinical experiences7. A copy of any text being used for the course8. Calendar indicating school holidays and breaks as well as a

breakdown of student schedules away from the clinical unit9. Room assignments for pre and post clinical conferences10. Copy of rotation schedule and clinical objectives for each unit11. Letter for Nursing Education Department Nurse Manager

verifying student CPR, malpractice insurance, andimmunizations

12. Orientation responsibilities13. Facility specific formats for documentation, drug

administration (Pyxis machines), information retrieval,procedures and protocols

14. Letter to facility liaison person and unit managers to alert staffto beginning of a new clinical rotation (See pg.4 for data toinclude in memo)..

15. Contents of student evaluation forms, needsimprovement/learning experience plan, educationalagreement; how to complete them; timeframes for evaluation

16. Absenteeism policy and make-up assignments17. Written assignments -- nursing care plans, mind maps, reports

.Purpose: The purpose of this rotation is to provide the registered nursing ·students with an opportunity to

witness perinatal case management by nurse practitioners in the out patient setting,

I. Student Prerequisite Knowledge:

I. Review NR 16 antepartal and postpartal nursing assessments and patient teaching content.2. Review NR 12 family planning content.

II. Student Objectives:

1. Discuss the impact of managed care and case management in matemal•neonatal nursing.2. Describe activities associated with the advanced practice nursing role in the perio.atal clinic.3. Using the Sierra College Nursing Department Log, track the- visit of each client. Document the reason for

her visit, observations, interventions and your rationale & comments. Include the following information:a. Regarding the client's pregnancy:

l) ·Explain patient teaching for matemaVfeta1 assessment2) Delineate guidelines for interventions and evaluation of therapies3) Identify the schedule of perinatal visits.for a WOJl!an experiencing a normal pregnancy.4) Evaluate cultural influences of the womanis (family's) response to pregnancy (complication 'of

pregnancy) and the use of the health care system.5) Identify special intrapartal and postpartal considerations6) Family planning interventions.

b. Identify agency specific infonnation:l) Philosophy and goals of agency2) Type of agency (profit or non•profit) (private or public)3) Cost of service reimbursement sources, I.E. Medicare4) Population served5) How can this agency assist your patient and/or family in adaptation6) By. whom and how is a referral made

Ill. Orientation-Staff:

J. All students are in _________________________________ Nursing Program.2. Students have signed a confidentiality statement.3. Student hours: 9:00AM •· 5:00PM (Tuesdays, Wedsnesdays, or Thursdays); one student/clinical day4. This rotation is observation only.5. Students are to adhere to policies/procedures of ------Hospital Materni ty Center.6. .lnstructors•Theory: •········---, RN, MSN (vnail) 916···---- (pager)---

Clinical: -----···· RN, MSN (vmail)9lo---•·········

IV. Orientation-Students:

I. The Hospital Materoity Center is located at--------------.

2. •-----, NP is in charge of ihe Perinatal Clinic;•··--············-· is the Registered Nurse ...3. Hours for your clinical experience are Tuesday, Wednesday, or Thursday 9:00AM • 5:00PM.4. Dress code•· neat street clothes with lab coat. Please wear your name tag.5. lf you ar� unable to attend on your assigned day, please notify the Perinatal Clinic at •·---­Objectives are to be turned in on Thursday following your assigned day.

NURSING PROGRAM CLINICAL ROTATION

Course: NR12: Nursing the adult with Common/Remedial Health Problems

Clinical Days/Times: 2/11 – 3/12 Monday 1100 – 1300Tues/Wed 0630 – 1300

3/18 – 5/14 Tues/Wed 0630 – 1400 (no scheduled prep time)

Instructors:

Student Information1. Second semester RN students.2. Student phone numbers are on file in your nurse manager’s office.

Immunization and CPR information is on file in the college NursingDepartment.

General Student Objectives/Expectations:1. Within agency policy, able to perform the skills on the attached skills list with

supervision of the instructor as appropriate.2. Plans and implements care for 1 –3 patients.3. Provides care in the context of the RN role, utilizing assistive personnel (such

as nursing assistants) when appropriate.4. Prepares all medications under the direct supervision of instructor or staff RN

before administering to assigned patients. Includes: dosage calculations, fiverights, procedure/approach to patient, knowledge of drug.

5. Administer injections, IV fluids, and IV medications to adult patients onlyunder the direct supervision of the instructor. Students do not give IV pushmeds (per agency policy).

6. Correctly documents all care (including meds and treatments) according toagency policy. Keeps documentation up-to-date throughout shift.

7. Reports on and off unit to Staff RN/Charge nurse and instructor.8. Has completed Sierra College patient information and care planning sheets

prior to beginning care.9. Completes Staff/Student communication form before beginning shift.10. Maintains patient confidentiality at all times. Signed confidentiality forms are

in the students’ files at the college.11. Notifies the assigned unit and the instructor if absent due to illness, or if

she/he becomes ill or injured during clinical time.

STUDENT AND STAFF COMMUNICATION FORM

Student Name: Semester:Unit: Date: Patient Rm. Patient Initial:

Instructions: When assuming co-responsibility for a patient, thestudent will share with the RN the following information:

Task I perform independently for this patient(s):

Tasks for which I call the Instructor: (enter time also)

Tasks/procedures for which the staff RN will be responsible:(enter time)

Daily Student Learning Objectives: (may include experiences desired but not available with your patient)

FROM STAFF RN: Information to be reported to RN by the student

FEEDBACK OR COMMENTS: (from staff or instructor)

STUDENT AND STAFF COMMUNICATION FORM

Student Name: Semester:Unit: Date: Patient Rm. Patient Initial:

Instructions: When assuming co-responsibility for a patient, thestudent will share with the RN the following information:

Task I perform independently for this patient(s):

Tasks for which I call the Instructor: (enter time also)

Tasks/procedures for which the staff RN will be responsible:(enter time)

Daily Student Learning Objectives: (may include experiences desired but not available with your patient)

FROM STAFF RN: Information to be reported to RN by the student

FEEDBACK OR COMMENTS: (from staff or instructor)

DEGREE NURSING PROGRAM

NAME_________________________ TITLE____________________ DATE____________

HOSPITAL______________________ SCHOOL_____________________________________

CLINICAL INSTRUCTOR__________________________________________________________

STUDENT ORIENTATION CHECKLIST

This checklist is to be completed once for each functional area worked BEFORE patient contact or care is assigned or provided. You are encouraged to keep this checklist for your reference. Return a copy of this completed checklist to your clinical instructor.

Unit Specifics

____Introduction to staff on duty: Names and titles____Charge RN name_______________________________________________________________Assigned Team Leader or Resource RN name________________________________________Shift hours and report times__________________________________________________

Type of report______________________________________Report expectations for you______________________________________

____Physician Order Communication Process____Physician Notification Process: Who, What, When, How____Charting/Special Documentation Requirements for area: (forms, plan of care)

_______________________________________________________________________________________________________________________________________________________________________________________

____Location of Unit/Department Standards Manuals (Policies, Procedures, Protocols,Guidelines)

Care Delivery

____Chain of command and communication expectations____Role functions of staff on unit: Who does what?____Specific care requirements unique to patients on this unit/department:

(assessments, I & O, etc.)____Patient Confidentiality and Rights____Medications: Who is responsible for:

Scheduled Meds (other than IV)________________________________________PRN Meds__________________________________________________________IV Meds____________________________________________________________

Safety

____Safety Procedures for activities that might pose safety hazards in the work area____Location and use of personal protective equipment

Life Safety

____Personal role in a fire (R.A.C.E. steps)____Alarm locations____Fire Extinguisher (location, types, use)____Code Red phone #____Evacuation exits and plan for unit____Emergency power (red outlets)

Security

____Role in handling a security problem• Theft_____________________________________________________

• Assaultive behavior__________________________________________

• Suspicious activity___________________________________________

Hazardous Materials and Waste

____Location of sharps containers on unit and proper disposal____Hazardous chemicals used in this unit/department that might be encountered in job role:__________________________________________

• Safe handling• What to do if a spill occurs

____Location of MSDS sheets and what information is on them

Student Signature Clinical Instructor Signature

Date Date

RETURN A COPY OF THIS COMPLETED CHECKLIST TO YOUR CLINICALINSTRUCTOR.

SIERRA COLLEGENR10 CLINICAL ORIENTATION TREASURE HUNT

Match each of the items below with the letter corresponding to the area/room in which it wasfound. Try to find them by helping each other and without asking the staff first

A. Nurse’s station B. Clean utility roomC. Hallway D. KitchenE. Dirty utility room F. Medication roomG. Treatment room

____student assignment sheet ____unit telephone number____policy and procedure manuals ____patient charts____medication kardex ____medication carts____emergency cart ____syringes & needles____restraints ____specimen cups (urine, stool, etc.)____denture cups ____nonsterile gloves____tea, coffee, sugar, juice ____patient information plates____dressing supplies ____refrigerator for patient/staff food____lab order forms ____admission kits____bedpans urinals ____alcohol wipes____blood pressure cuffs ____scales (standing, bed)____medication refrigerator ____patient census board____patient kardex ____patient care items (razors, lotions,____thermometers slippers, etc.)

Locate and learn the operation of the following items in patient rooms:

lights nurse call lightbathroom bed controlsemergency call light telephonebed controls overbed tableoxygen, suction outlets

Also locate the following:

Visitor, staff bathrooms_______________________________________________Linen closet_________________________________________________________Tub/shower room____________________________________________________Fire alarms__________________________________________________________Fire extinguishers____________________________________________________

NR10 TREASURE HUNT

STUDENT OBJECTIVES FOR ORIENTATION

At the end of orientation, the students will be able to:

1. Verbalize basic information about units and the assigned hospital ingeneral.

2. Describe the services and departments available for patient care at theassigned hospital.

3. Discuss student and instructor expectations for this clinical rotation inNR10.

4. Find information to be collected on Mondays, during pre lab or preptime.

5. Specific to the assigned hospital, describe policies and proceduresregarding Safety, Documentation, and Infection Control

SIERRA COLLEGEASSOCIATE DEGREE NURSING PROGRAM

NR 10 STUDENT LEARNING OBJECTIVESFirst day on units – Wednesday

Nursing students will be assigned to a patient care team (RN, CNA, SP) with thefollowing objectives to be met:

1. Work closely with RN (or other team members) in providing care toassigned patients.

a. Give basic hygiene and comfort care with assistance/supervision ofthe staff RN and/or instructor. Examples: bathing, ROM,positioning, and feeding.

b. Assist with ambulation and transfer of patients under thesupervision of the staff RN and/or instructor.

2. Become familiar with the documentation system in use on the student’sassigned unit.

a. Locate a patient chart and note how it is organized.

b. Identify and locate the chart forms the nurse uses for charting.

3. Complete the unit “Treasure Hunt” and “Student Orientation Checklist”,paying particular attention to the location of the following”

• Fire alarms and extinguishers• Fire exits• Nursing policy and procedure manuals

SIERRA COLLEGE

ASSOCIATE DEGREE NURSING PROGRAM

STUDENT OBJECTIVES FOR SECOND WEEK OF CLINICAL

Students will be responsible for:

1. Hygiene, comfort, and safety measures (ADLs) on their assignedpatient.

2. Vital Signs (VS) and head-to-toe baseline assessment on their patient.Student will write out the assessments on a separate piece of paper toshow instructor, and discuss assessment findings with the staff RN.

3. Charting only on the graph sheet of the chart (VS, weight, diet,activity) after first checking with the staff RN or instructor.

4. Listening to entire morning report at 0700 with the team.

5. Reporting off to the staff RN and instructor when going on their 15minute break and 30 minute lunch. Also report off to staff RN beforeleaving for the day at 1130.

Sierra College A.D.N. ProgramPediatric Clinical Day Absenteeism: Optional Activities

Because of the numbers of pediatric clinical days, you must complete any one ofthe following assignments in place of the missed clinical experience:

I. Pediatric Grand Rounds

University of California, Davis, Medical Center2315 Stockton BoulevardSacramentoAuditorium, Fridays 8:00 AM – 12:00 PM

Write a log of information obtained from Grand Rounds which includes thefollowing information on each client:1. Diagnosis, explanation of the diagnosis and how the diagnosis impacts

the patient.2. Delineate guidelines for interventions and evaluation of therapies.3. Pertinent assessments.4. Lab tests, procedures – pertinent to diagnosis/problems (why done,

result even if normal and rational for results)

II. Pediatric Computer Programs

You may view computer programs available through the NursingDepartment school. Call and make arrangements with Sandy or Marlene ifyou are choosing this option.

Fill out one “Computer Program Evaluation” for each program reviewed.

Computer Program list:Medi-Sim Computer Assisted Instruction – Pediatric Nursing· Infants· Toddlers· Preschoolers· School Aged Children

III. Pediatric Videos in Main Library

Instructions to view videos:1. You must first have a library card2. The video counter is located to the right after you enter the library area

on the third floor.3. Choose 4 videos from the list below and fill out the check-out card at

the video counter.4. You will be issued a set of head phones to use when watching the

videos at the viewing booths. There is also a room that will hold 5 or 6people who want to view a video as a group.

5. Fill out one “Video Evaluation” form for each video and return it to theinstructor.

Library Videos:

Children’s Health in the Community NLN VideosGrandparents Raising Grandchildren Terra Nova FilmsHuman Development – Conception to Neonate Concept MediaTo Touch a Grieving Heart Panacom VideoTouchpoints with Dr. T Berry Brazelton (3 vols) Aquarius ProductionsWhen the Bough Breaks Fanlight Productions

SIERRA COLLEGECOMPUTER PROGRAM EVALUATION

STUDENT NAME ___________________________________________

NAME OF COMPUTER PROGRAM ______________________________

LENGTH OF PROGRAM ______________________________________

Please evaluate the computer program by answering the following questions:

1. Was the information on the program clear and easy to understand?Yes No

2. Did you feel the information was current and up to date? Yes NoPlease list any information you have a question about or that was not clear.

3. What did you like best about the computer program?

4. What did you learn from the program that was new for you?

5. How will you use the new information in your patient care?

6. Please add any additional comments/suggestions.

RETURN FORM TO NURSING INSTRUCTOR

SIERRA COLLEGEVIDEO EVALUATION

STUDENT NAME___________________________________________________

NAME OF VIDEO __________________________________________________

LIBRARY CATALOGUE NUMBER OF VIDEO ________________________

LENGTH OF VIDEO ________________________________________________

Please evaluate the video by answering the following questions:

1. Was the information on the video clear and easy to understand?__________________________________________________________________________________________________________________________________________

2. Did you feel the information was current and up to date?Please list any information you have a question about or that was not current.__________________________________________________________________________________________________________________________________________

3. Please rate audio-visual quality of the video.If the video was of poor quality, please comment on the problems, i.e., fuzzy picture,hissing on tape, rolling, black lines, etc.__________________________________________________________________________________________________________________________________________

4. What did you like best about the video?__________________________________________________________________________________________________________________________________________

5. What did you learn from the video that was new for you?__________________________________________________________________________________________________________________________________________

6. How will you use the new information in your patient care?__________________________________________________________________________________________________________________________________________

7. Please add any additional comments/suggestions.__________________________________________________________________________________________________________________________________________

RETURN FORM TO NURSING INSTRUCTOR FOR CREDIT

Appendix D The College Laboratory

Setting

Computer Program Evaluation Video Evaluation

Student Skills Evaluation

SIERRA COLLEGECOMPUTER PROGRAM EVALUATION

STUDENT NAME ___________________________________________

NAME OF COMPUTER PROGRAM ______________________________

LENGTH OF PROGRAM ______________________________________

Please evaluate the computer program by answering the following questions:

1. Was the information on the program clear and easy to understand?Yes No

2. Did you feel the information was current and up to date? Yes NoPlease list any information you have a question about or that was not clear.

3. What did you like best about the computer program?

4. What did you learn from the program that was new for you?

5. How will you use the new information in your patient care?

6. Please add any additional comments/suggestions.

RETURN FORM TO NURSING INSTRUCTOR

SIERRA COLLEGEVIDEO EVALUATION

STUDENT NAME___________________________________________________

NAME OF VIDEO __________________________________________________

LIBRARY CATALOGUE NUMBER OF VIDEO ________________________

LENGTH OF VIDEO ________________________________________________

Please evaluate the video by answering the following questions:

1. Was the information on the video clear and easy to understand?__________________________________________________________________________________________________________________________________________

2. Did you feel the information was current and up to date?Please list any information you have a question about or that was not current.__________________________________________________________________________________________________________________________________________

3. Please rate audio-visual quality of the video.If the video was of poor quality, please comment on the problems, i.e., fuzzy picture,hissing on tape, rolling, black lines, etc.__________________________________________________________________________________________________________________________________________

4. What did you like best about the video?__________________________________________________________________________________________________________________________________________

5. What did you learn from the video that was new for you?__________________________________________________________________________________________________________________________________________

6. How will you use the new information in your patient care?__________________________________________________________________________________________________________________________________________

7. Please add any additional comments/suggestions.__________________________________________________________________________________________________________________________________________

RETURN FORM TO NURSING INSTRUCTOR FOR CREDIT

SKILLS EVALUATION

Student: ____________________ Date: _____ _ Skills must be passed with 100% proficiency. Bring this form wit:, you to your check of You will also need to bring the suction catheter kit you purchased

Pass Fai erti p ormance Attemnts: l

Tracheostomy • Washes hands

Suctioning • Gathers appr0priate supplies• Informs client of procedure• Assesses suction working• Places client in semi-Fowler·s position• Listens to breath sounds• Evaluares pulse oximeo-y reading• Opens suction kit in sterile manner• Pours water/saline into cup• Wears face/eye protection• Protects client gown from secretions• Hyperoxygenates client if needed• Attaches suction catheter to suction tubing using

sterile technique• Lubricates catheter tip with sterile saline or water• Gently insert catheter into trach until slight

resistance is felt or client starts to cough ( suctionI 10-120 mmHg)

• Apply intermittent suction while withdrawing . catheter in a !Wisting motionover 5 to IO seconds using thumb and forefinger

• Reapply oxygen or hyperventilate client• Using continuous suction rinse catheter in

water/saline• Allow client to rest between suctioning• Repeat suctioning steps. as needed to remove

secretions• Suction oral pharynx/nares if needed• Rinse catheter in water/saline at end of procedure• Tum off wall suction• Disconnect suction catheter, coil. and discard in

glove.• Wash hands• Reassess breath sounds/pulse oximetry• Assess client's tolerance 10 procedure• Washes hands• Documents

�pplication of • Applies correct appliance based on Fi02 ordered}

Oxv!!en

!!:valuator:

:-'.nmment�:

Appendix E Facilitating Learning in the

Clinical Practice Setting

Socratic Questions Clinical Questions

Critical Thinking Model Nursing Care Plan

Socratic Questions

Clarification Questions� Tell me about your client’s condition/problems/needs.� What is the most important client/family/community problem? Why?� What do you mean when you say ______?� Give me an example of ______.� How does this new information relate to our earlier discussion of the

family’s care?

Questions to Probe Assumptions� You seem to be assuming that your client’s responses are due

to ________. Tell me more about your thinking here.� What assumptions have you made about ______?� On what data have you based your decisions? Why?� Your decisions about this client/family/community are based on your

assumptions that ______. Is this always the case? Why or why not?

Questions to Probe Reasons� How do you know that ______? What are other possible reasons for

______?� Tell me why ________?� What would you do if _______? Why?� Is there a reason to question this information? Decision? Approach? Why?

Questions of Differing Perspectives� What are other possibilities? Alternatives?� How might the client/family view this situation? Does anyone (in the

clinical group) view this differently? Why?� Tell me about different interventions that might be possible and why each

one would be appropriate.� What are other ways of approaching the staff?

Questions on Consequences� If this occurs, then what would you expect to happen next? Why?� What are the consequences of each of these possible approaches? What

would you do in this situation and why?� What would be the effect of ------- on the community?� If this is true, then what?

Note. From Oermann, M.H. (1997). Evaluating critical thinking in clinical practice. NurseEducator, 22(5), 25-28. Copyright 1997 by Lippincott, Williams, & Wilkins. Reprintedwith permission.

Clinical Questions

Suggested Clinical Questions to ask each student on a daily basis when studentsare providing direct patient care:

After hearing shift report and doing your initial patient assessments—whatproblems do you anticipate in providing the prescribed care and why? How doyou plan to resolve each of the anticipated problems?

What meds, treatments/procedures etc. will you be performing today and when?

Do you have any documentation questions related to the care you will beproviding today?

Who is your sickest patient and why — intent of the question is for the studentto recognize and prioritize care for real and potential patient patho andcomplications in conditions/treatments.

Identify the top three priorities of care for each of your assigned patients.Student responses should reflect the student’s knowledge and understanding ofeach patient’s condition/patho and response or lack of response to treatment.Discuss each priority of care, patho and treatment response as needed.

If you were making rounds with the physician today, what essential informationwould you want the physician to know about each of your patients and thepatient’s response/lack of response to treatment, etc.?

If any of your patients have abnormal lab values or medication issues — whenwas the physician notified of the abnormality, etc.? What interventions are beingimplemented to address the identified problems…patient response?

When would you expect the abnormality to be corrected? — Explain asnecessary.

The unit manager or supervisor is making shift rounds, what essentialinformation do you need to tell the supervisor about the patients in your care?

If you or your staff buddy is having difficulty getting a call back from thephysician when there are serious patient condition or treatment concerns, whatdo you need to do immediately and what can realistically wait?

CRITICAL THINKING MODEL

• List & prioritize current problems

• List & prioritize potential problems

• What more data is needed?

• What assumptions are made?

• At least 3 possible reasons for the problem

• List appropriate goals

• Identify at least 3 methods of achieving the goals

• How will these methods have their effects?

• (+) and (-) spill-over effects

• Decide and act

Patient lnfonnation and Care Planning Sheet

Student Name. __________ Date(s) of care ____ _

Patient lnitials, ____ Room, ___ D,r. ______ _,Admit date. __ _ Age ___ Allergies, _____________________ _ Current Medical Diagnosis/problem ________________ _ Other Health Problems, _____________________ _ Previous hospitalizations/surgeries (date/reason), ____________ _

Family/CutturaVEthnic background, _________________ _

Discharge Plans _______________________ _

CURRENT DIAGNOSIS/MEDICAL PROBLEMS (summary of H&P, MD progress notes, pathophysiology, pertinent lab data):

1

As�cssmcnt Mode

Physical Ncc,ls

-··

NllHSINCl PROGRAM

NIIRSIN(i CARE Pl.AN

rrohlcm SlalCllll'PI or ral:lent Interventions & 1 each ing Nursing Diagocisis outcomes

NCLUDE J PARTS N. DIAGNOSI,

E\·aluation/ Hcvision

..

Appendix F The Clinical Practice

Setting

Student Nurse Time Management Student Nurse Worksheet

Nursing Instructor Worksheet Clinical Rotation Journal

Interpersonal Process Recording Interpersonal Process Recording Example

CLINICAL ROTATION JOURNAL

Student: Date: Date: Scheduled time: In ___ Out

Reflection: l. What I did well today:

2. What didn't go well today:

Resolution: 3. What course of action I will take next time:

Daily goals:

4. Goals met &/or not met. (If goals not met, why?)

MENTAL HEALTH

l'licnt 'a mmc/.tgc: Val, JS Y"'·

NURSING PROGRAM

- ..... - .. -----------

Date

of Interaction _____ _

flricfcllcnl profile: Val pr=nlly live,, In a 1upttVi•«I rc,idcnt.lal 1ellin,:. Tw" wc,:l<• ai,, •he,,.�., pu1idp,tin11: in the ,,.,1;.1 ho•pi1oliia1io11 rrog,•m •t doc lo<:•I rnc111:a1 liufth ccnlcr, She ha.� had many hMpitalizatia11t1•11hc elate hOJ1pital. The lccalmc:nl p1ao �Dllltt indu.,l c nu,od �1ahili1.:aUn11, 1uctlic11tiun c:om1,Ha1u.:c. lcarnin� ln<lcrcndcnt ,\I) l.'1 and teaming 1ppr0oprlat• coping 1l<i111. She hH dilrocully .,.i.1,11,hinl( rct.1ion�loil"'. She """'"" on •lro1111ly •ntl 11,cn l><.,:omc,< •o •nxiuu• 11,., •he wilhJuw•l• .. She h•• rapid mood swini;:s from bcln,e very quiet 10 lauj!!hiRI! inappropri•tcly lo pnllinJ!: her hc-,cl clown tlll lhc 'labk hllhnnl(h •he �milc,o r,cciucnlly, 11 licltavior appears lo •n anxiou• reaction-more 111111111 cxp,.,..l011 ofhappln..-. She h111 been tlllJ!:IIO.l-d with •cbli<oaffcciivc tli11u«lcr,

Bhort-tcmt gr,1/s for thc·one-to-one inlcnclion; This la the fln,I time I am mccling Val. l\ly I:""' i• lo lei her ••r•""" hcr,fccll11J!:' »nd heir her focu, 011 one loric •• time.

ficudcnt'• Communication

•Could you tell n••• whal your p,•1• arc for 1oJa7r

"Yc,i, I'll l,c your rricncl." fSmilln.f!f

Cllcnl'• c .. rnmunlcation

•1 dotl'l know. I don't need C(t hi! lt.ere·, l'L-or1c m11ythink I'm crazy but I'm not. I do11'I have •ny frie11cl�.Will you be my fr!eud?" j'l'l,c wh .. lc lime ,he ls r0<;kl11f!back ind forlh, chau,:ln,: [1i1<11llons. Her faci•IcxprCMlon I• dm1gi1111 frorn "'11ili11j!! lo very �crlou.< 111tlhack lo •millnJ?, Her kl!>' are �rt,..,.ed aml •he i• looltli1111a 11nd1 c,11 whh hoth ''""''"· Siu: m•k<1< ,·cry lilflc eye�on«act.1

•Thank you, Vou 1,c Ruch fl ok-c: 1,uly."

�a

Analy�i• ofStudcnl'• anti Client'• lt!"'ponoc (verbal anti nonvcrh■l)

Jlrm,d ,,,,1:1,lu� Ap11CRr.: Id,,., ••c-,;,r .,,x;ur,,'f au, 11crsfnt1!I. lier l'Olt•c t:<>ltml� liln." �f,c NI !fC.'Wir1''{ l1.111py lo /,swc .,,,,,,.,,,c to l�lk 1,� 17,. ll'#f ,/,. uys :ilrc lutff IIP fn"c11tl., s111111d'{ like sl,c i11 N�rf ;11.

/,;:, ,·crJ' /,nr .ttdf..t..""l/cc11,. Sire! iii 11/.(tJ 11si1tf! Ille,lcU•,,�·r 111ct.J1:111i�11, or ,ln1inl.

Ofli:rit1!( xclt: lfrc11 tlm111l1 nu h,rc i11 d

11n11i.-:-.."·io11;f/ n,/c:1 I 1!1i111f she 11,·,·J.� t,, lu:i- //,c

n·m-d 1'/rfout/11 RI I/Ji.� 11w111c:11/. ,�,,,� n:l/c,·,·d

tlutl �·a111c.'f>J1<-• ,:" l,,,,·,,K ttin.• to lier, lh·lp ... !,er Ii.bdt,·r »bm,1 /t,:t:-.-cll

Appendix G Evaluation Strategies for the

Laboratory and Clinical Practice Setting

Needs Improvement Form

Educational Agreement Form

NtJRSING PROGRAMS

NEEDS IMPROVEMENT/LEAl!NrNG EXPERIENCE PLAN

Student Course

Date Semester

Observation ( s) indicating difficulty in meeting course objectives :

The above observation (s) indicate (s) that in order to show progress toward meeting the course objectives, the student should:

Student Course

Date Semest:er

NURSING DEPARTMENT

EDUCATIONAL AGREEMENT

Semester: --------

Date; ------

In keeping with the guidelines of the College Nursing Department, the fuculty is establishing the folbwing educational agreement with:

Course: -------------- ------------

O b j e c ti v es, which have not been met (and/or policie:i/procedures to which there has not been compliance):

Since the student's perfonnance is not consistent with the standards and requirements of the course objectives, and/or not in compliance with the policies set forth in the Nursing Program Student Handbook, or in the individual' hospital's policy manual. the following is a statement of eiq>eetations. To assist the student, the instructor will:

The student will:

Appendix H Mind and Concept Mapping

How does a student learn? What is a concept map?

Advantages of CCMs over Traditional Care Plans Implementations of CCMs

Assisting the Student in CCM Development Student Evaluations of CCMs

Faculty Response to Using CCMs rather than Traditional Care Plans

Mind Mapping

Clinical Correlation MapsCurrent move from a teaching college toa learning college

Mind Mapping

How does a student learn?Breaks new knowledge into small parts,or concepts/sub-conceptsArranges and reorders concepts tomake senseMakes connections between andamong concepts (most Difficult)

Mind Mapping

Graphic organizers help learner make connections among concepts, which in turn stimulates & develops critical thinkingAlgorithmsDecision-making treesMind Maps/ Concept Maps

What is a concept map?

A visual learning tool that represents and organizes pieces of knowledge, showing relationships where they exist

Advantages of CCMs over Traditional Care Plans

Care plans are lengthy & redundantCare plans are linearStudents often copy information onto their care plans from books

Implementation of CCMs

Poster boards or butcher paper usedCentral topic centered on mapWeb site accessed for free software trial, inspiration.com

From Inspiration.com

Implemenations of CCMs

Patient selection based on classroom theoryRelationships identified between conceptsCoded by color and shapesKey identified coding

Implemenations of CCMs

New map due every 1-2 weeksCan collaborate with another student(not all students visual learners)Shared weekly in post-clinicalconferenceRoundtable discussion on conceptualrelationshipsThinking “out loud”

Assisting the Student in CCM Development

Start with a columnar care plan, cut it apart, put it on poster board“Post It” notesColorsShapes

Student Evaluations of CCMs1. How did it clarify patient information?

Considered aspects of NP & patient care that get overlooked on a busy daySaw connectionsGood, visual pictureSaw relationships with drugs, why taken, adverse effects, how they affect lab values

Student Evaluations of CCMs2. Time factor?

Usually took 1-10 hours

Student Evaluations of CCMs3. What were the steps taken in development?Data from chart, textbooks to organize & finalizeData from nursing report and patient info gathered throughout the dayStart with general diagnosis, include all clinical data, add nursing diagnosisGather info on disease, tape on board, analyze connectionsRough draft first, a care plan outline helped

Faculty Response to Using CCMs rather that traditional Care Plans

Students see connections of concepts and therefore better understand themStudents can relate theory to clinicalCCMs are easier and faster to evaluate and grade

21

Bibliography

Bell, M.L. (1991)Learning a complex nursing skill: Student Anxiety and the effect of preclinical

skill evaluation. Journal of Nursing Education, 30, 222-226.

Chickering, A. & Gamson, Z. 1987. Seven Principles for Good Practice in Undergraduate

Education. AAHE Bulletin, March.

Halstead, J.A. (1998) The academic performance of students; Legal and ethical issues.

(pp.37-50). In Billings, D.M. & Halstead, J.A. Teaching in nursing: A guide for faculty.

Philadelphia: W.B. Sanders.

Infante, M.S. (1985). The clinical laboratory in nursing education (2nd ed.). New York: Wiley

Oermann, M.H. & Gaberson, KB. (1998) Evaluation and testing in nursing education. New

York: Springer.

O'Connor, A. (2001) Clinical instruction and evaluation: A teaching resource. Boston: National

League for Nursing.

Reilly D.E. & Oermann, M.H. (1992) Clinical teaching in nursing education (2nd ed.). New York:

National League for Nursing

Stokes, L. (1998) Teaching in clinical settings. In D.M. Billings & J.A. Halstead (Eds.) Teaching

in nursing: A guide for faculty (pp. 281-297). Philadelphia: Saunders.