Choose one of the clinical learning situations below and suggest ways to create a successful learning experience. Also comment on how the topic could be applied in other settings (academic and online). Refer to Teaching in Nursing: A Guide for Faculty (Chapters 17 and 18), New Technologies in Nursing Education, and A Vision for the Changing Faculty Role: Preparing Students for the Technological World of Health Care to support your suggestions.
The clinical learning situations are as follows:
- A high-fidelity simulation addressing care of a patient with congestive heart failure
- A six-hour clinical rotation addressing patient care given on a telemetry unit
- A low-fidelity simulation addressing the psychosocial care of a suicidal patient
Teaching and Learning Using Simulations*
Pamela R. Jeffries, PhD, MSN, RN, FAAN, ANEF;
Sandra M. Swoboda, RN, MS, FCCM;
Bimbola Akintade, PhD, MBA, MHA, ACNP-BC, CCRN
The complexities of the health care system coupled with a changing patient population have created a need for nursing students to be prepared to care for all types of patients in a variety of care settings. Additionally, as health care shifts to community settings, nurse educators have been challenged to find appropriate clinical sites and clinical experiences for nursing students to meet curricula competencies and required clinical experiences. Because of these challenges, nurse educators are exploring alternative strategies for clinical preparation for nursing students. Simulation offers nurses, students, and health professionals the opportunity to learn in situations that are comparable to actual patient encounters within a controlled learning environment (Alden & Durham, 2012; Katz, Peifer, & Armstrong, 2010) that supports the learners’ transfer of classroom and skills laboratory knowledge to realistic patient interactions (Anderson & Warren, 2011; Halstead, 2006; Meyer, Connors, Hou, & Gajewski, 2011). Clinical simulation technology is becoming increasingly more realistic, and nursing programs are making substantial investments in equipment and learning space. As simulations and related teaching and learning strategies move into nursing programs, and evidence supports clinical simulations as an alternative to actual clinical experiences (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014), nurse educators must be prepared to teach using this methodology.
This chapter discusses simulations as an experiential, student-centered pedagogical approach. The chapter begins with an overview of types of simulation—the purposes, challenges, and benefits of clinical simulations—and concludes with information about planning, implementing, and evaluating simulations as they are integrated into courses and curricula. The chapter emphasizes (1) the types of clinical simulations being developed and implemented in nursing programs; (2) challenges and benefits to student learning, thinking, and practice; (3) a framework and steps to consider when developing and using clinical simulations; and (4) the evaluation component to consider when implementing simulations in the teaching–learning environment.
Simulations are activities or events, such as performing basic life support on a patient simulator to manage a cardiac arrest, that mimic real-world practice. Simulations are used when real-world training is too expensive, occurs rarely, or puts participants (or patients) at unnecessary risk. Simulations provide the opportunity for students to practice within their scope of practice, think critically, problem solve, use clinical reasoning, and care for diverse patients in a nonthreatening, safe environment. Incorporating simulations into a nursing curriculum as a teaching and learning strategy offers nurse educators the opportunity to support learners’ educational needs by providing them with an interactive, practice-based instructional strategy.
There are various types of simulations. The terms used to describe various aspects of the simulation experience are described here. The simulation nomenclature matrix includes learning domains and tool and environmental realism. Tool and environmental realism are further categorized into types of 305fidelity—low, medium, and high—and the context of the fidelity as partial or full.
Fidelity, or the realism of simulations, is described along a continuum—from low fidelity to high fidelity—relative to the degree to which they approach reality.
• Low fidelity: This type of simulation experience includes case studies to educate students about patient situations, role playing, the use of a partial task trainer or static manikin (e.g., plastic model arm to learn how to perform a venipuncture, wound care trainer for wound management) to allow students to perform a task or skill. Low-level realism is present; however, principles and concepts can still be learned using this type of simulation (International Nursing Association for Clinical Simulation and Learning [INACSL] Board of Directors, 2011).
• Medium fidelity: This type of simulation is technologically sophisticated in that the participants can rely on a two-dimensional, focused experience to solve problems, perform skills, and make decisions during the clinical scenario. These manikins have the ability to auscultate heart sounds and breath sounds but the chest does not rise. Some examples include VitalSim Anne and VitalSim Kelly.
• High fidelity: This type of simulation involves full-scale, high-fidelity human patient simulators, virtual reality or standardized patients (actress or actors portraying simulated patients that have certain health disruptions) that are extremely realistic and provide a high level of interactivity and realism for the learner (International Nursing Association for Clinical Simulation and Learning [INACSL] Board of Directors, 2011). Examples include SimMan 3G, SimNewbie, iStan, and METI HPS, as well as a birthing simulator called Victoria and her newborn infant, all of which permit the student to listen to various body sounds and can be programmed to talk and to respond to interventions performed by the students.
Partial or Full-Context Simulations
The context of simulations can be partial or full.
• Partial task trainers: Partial task trainers are those simulations in which a body part, plastic model, or partial manikin is used to depict a certain function and on which a student can practice a particular psychomotor skill. Examples of partial task trainers include intravenous (IV) cannulation arms and low-technology manikins that are used to help students practice specific psychomotor skills integral to patient care such as inserting urinary catheters or nasogastric tubes.
• Full-context simulations: These simulations include the full context of a scenario, an event, or an activity that replicates reality. For example, a static manikin with limited functions such as VitalSim Kelly is full context but medium fidelity. The full context of an event can be represented using this type of simulation in a low-fidelity manner. High fidelity, full context is a simulated learning experience using a high-fidelity simulator and immersing the participants in a realistic mock code situation or a simulated live birth.
Full-scale patient simulations using sophisticated, high-fidelity patient simulators provide a high level of interactivity and realism for the learner. Less sophisticated, but still educationally useful, are computer-based simulations in which the participant relies on a two-dimensional, focused experience to solve problems, perform skills, and make decisions during the clinical scenario. Studies have shown that the two-dimensional experience has merit in terms of positive learning outcomes and skill acquisition (Jeffries, Woolf, & Linde, 2003). Partial task training devices such as IV arms and haptic (force feedback) IV trainers are used in simulations for psychomotor skills. The learner is able to practice a skill repeatedly before performing it on a real patient. The partial task trainers typically ensure a satisfactory rate of achievement of objectives and benefit to the participant. Studies have shown that after having used these task trainers, participants demonstrate a psychomotor skill and use that skill set in the real patient environment (Engum & Jeffries, 2003). Programs or courses in which the task trainers are used include clinical laboratory courses and modules during which specific skill sets and goals need to be obtained. Another approach to learning is the use of two-dimensional CD-ROMs to provide interactive practice with skills.
Types of Simulation
Simulations variously involve role playing, standardized patients (actors), interactive videos built 306on gaming platforms, and manikins to teach procedures, decision making, and critical thinking in realistic environments (Ryan et al., 2010). There are a variety of technology-based simulations to support student and novice nurses. They include computer-based interactive simulations, haptic partial task trainers, and digitally enhanced manikins. Haptic trainers use force feedback to provide opportunities to develop psychomotor skills. In addition to types of simulations categorized by the equipment or manikin used, there are simulations categorized by the type of pedagogy used when implementing the simulations. These types of simulations are described in the following sections.
A hybrid simulation is the combination of a standardized patient and the use of a patient simulator in one scenario to depict a clinical event for the learner. For example, the simulation scenario may begin with the student performing a health history on a standardized patient who has just arrived in the emergency department after having been involved in a motor vehicle accident. As the case evolves, the activity shifts to a patient simulator because of the clinical symptoms that need to be demonstrated by the manikin to reflect reality. This is a hybrid simulation because the history is being performed on a standardized patient and then the scenario shifts to a patient simulator, where the patient is now experiencing “hypovolemic shock” that is being reflected in the vital signs and other clinical findings of the manikin. A common hybrid simulation in obstetrics involves a low-fidelity task trainer with a standardized patient for simulations of normal birth or complications such as shoulder dystocia. This can be done with a standard actor and the pelvis of a birthing simulator or with the use of the Mama Natalie, which is a low-cost, wearable device that can manually deliver a baby and placenta and simulate postpartum complications.
Unfolding Case Simulations
Another type of simulation is the unfolding case. Unfolding cases evolve over time in an unpredictable manner. An unfolding case may include three to four events that build on each other, providing students an opportunity to plan care across a clinical event, a hospitalization, a care transition or across the life span (Page, Kowlowitz, & Alden, 2010). Unfolding cases can be used to meet a variety of learning goals:
1. To demonstrate hierarchal order so the learner can follow the progression of a health problem and the related nursing care. For example, the first scenario demonstrates the patient being admitted with a head injury caused by a fall; the learner must conduct a focused neurologic assessment. The unfolding case leads to a second scenario, in which the patient experiences specific neurologic signs (e.g., severe headache, widening pulse pressure); the learner must use additional assessment skills. The third case occurs postcraniotomy and involves care of the patient after the subdural hematoma is removed.
2. To visualize and prioritize hospital trajectory and care of a patient that progresses. For example, the patient is admitted through the emergency department, with the learner performing an assessment. The second scenario depicts the patient being admitted to the progressive care unit and the third scenario is designed for the learner to prepare the patient with discharge instructions.
3. To provide the learner with a view of care transitions, showing the effect of the health disruption or disease process and nursing interventions required for a particular patient. For example, the first scenario depicts a hospitalized patient newly diagnosed with chronic obstructive pulmonary disease (COPD). The second scenario progresses to the patient having compromised gas exchange related to COPD and being managed at an ambulatory care center. The third scenario depicts end-stage disease with a focus on end-of-life care with hospice care.
4. To serve as a mechanism to include a variety of important assessments and findings where one event leads to another. For example, the first scenario focuses on hypotension and subtle findings of sepsis and the second scenario centers on the critically ill patient with sepsis and hypotension.
Several organizations have developed unfolding case studies related to particular topics that are available at no cost to faculty. Four unfolding cases 307that focus on older adults and address the complexity of decision making about their care can be found at http://www.nln.org/facultyprograms/facultyresources/aces/unfolding_cases.htm; unfolding cases related to patient safety can be found at the Quality and Safety Education for Nurses (QSEN) site at http://www.qsen.org.
Standardized patients are live actors trained to portray the role of a patient according to a script or clinical scenarios written by the faculty. The actors become the patients, demonstrating clinical symptoms and responses of real patients. A variation of the standardized patient instructional strategy is the use of these types of simulations to evaluate physical assessment skills, history taking, communication techniques, patient teaching, and types of psychomotor skills or objective structured clinical examination (OSCE).
In Situ Simulations
In situ simulation is a type of simulation that involves training performed in a real-life setting where patient care is commonly provided (Dismukes, Gaba, & Howard, 2006). The aim of this type of simulation is to achieve high fidelity (realism) by performing the simulations in actual clinical settings, blending and providing both a clinical and learning environment. Typically, the simulation-based experiential learning focuses on interdisciplinary professional teams. Practicing professionals are well versed in their particular field, possess a fair amount of experience, and prefer their learning to be problem-centered and meaningful to their professional lives. Adults learn best when they can immediately apply what they have learned. Traditional teaching methods (e.g., a teacher imparts facts to the student in a unidirectional model) are not particularly effective in adult learning because it is important for adults to make sense of what they experience or observe.
Virtual Simulations and Digital Platforms
Simulations can also take place in virtual environments. Increasing development in virtual patient simulation is evolving and allows the learner to interact with the patient and the virtual environment where the patient is responsive to interventions through a digital media platform. An example of this platform is Second Life, a virtual world accessible by the Internet that enables its users to interact with each other through avatars. In this simulated world, users can explore, meet other users, socialize, participate in individual or group activities, and create services for one another or travel throughout the world. The software is a three-dimensional modeling tool that attempts to depict reality for the users. Second Life is used as a platform for education by many institutions, such as colleges, universities, libraries, and government entities. For the top 10 health care–related virtual reality applications, go to http://scienceroll.com/2007/06/17/top-10-virtualmedical-sites-in-second-life/.
There are other platforms whereby software programs replicate clinical practice and respond to learner interactions; some provide written feedback to the learner with suggestions and evidence as feedback. Simulation through game-based learning can be independently performed or moderated and this type of simulation helps prepare students for the clinical setting and allows the learner to make decisions and interact with a patient with real-time response in a safe learning environment.
Cook (2012) designed and evaluated a virtual world simulation for family nurse practitioner students and also created a primary care pediatric simulation for use by family nurse practitioner students in Second Life. Seefeldt et al. (2012) used Second Life to allow pharmacy, nursing, physical therapy, occupational therapy, and physician assistant students to interact around a mock patient case. The pilot study examined the feasibility of using Second Life as a means to foster interprofessional education (IPE). Students overall found the platform useful; however, there were technical difficulties in using the platform and students lacked the necessary knowledge and skills to use the platform. Farra, Miller, Timm, and Schafer (2013) found out that virtual environments can be used as a learning strategy for nursing students to practice and hone their disaster response and management skills. The study found that students were able to retain the knowledge after the simulation and there was an overall positive response to the use of the virtual platform.
Purpose of Simulations
Clinical simulations in nursing education can be used for many purposes, for example, as a teaching strategy or for assessment and evaluation, or as an avenue to encourage IPE. However, one of the most important reasons that educators use simulations 308is to provide experiential learning for the student. Students can be immersed in a simulation where they can actually portray the primary nurse, a newly employed nurse in orientation, or whatever role within the scope of nursing practice the learner is assigned.
Simulations as Experiential Learning
The use of simulation corresponds with a shift from an emphasis on teaching to an emphasis on learning (Dunn, 2004; Jeffries, 2005) in which the faculty facilitate learning by encouraging students to discover, or construct, knowledge and meaning. Kolb (1984) and others (Sewchuck, 2005; Svinicki & Dixon, 1987) suggest that the experiential learning cycle is a continuous process in which knowledge is created by transforming experience. Individuals have a concrete experience, they reflect on that experience (reflective observation), they derive meaning (abstract conceptualization) from the experience, and they try out or apply (active experimentation) the meaning they’ve created, thus continuing the cycle with another concrete experience.
When making a shift in approach from a focus on teaching to a focus on learning, goals of the educational programs serve as the framework for the development of specific learning activities. For example, both nursing students and novice nurses entering professional practice find it difficult to transfer theoretical knowledge into clinical practice. The use of simulation allows students to experience the application of theory in a safe environment where mistakes can be made without risk to patients.
The use of highly realistic and complex simulation may not always be an appropriate educational approach. In some situations, beginning students can use low-fidelity simulation to work on attainment of foundational skills, including effective communication with patients, psychomotor skill performance, and basic assessment techniques. With task trainers or standard manikins, students can practice procedural skills and caregiving in a safe environment that allows them to make mistakes, learn from those mistakes, and develop confidence in their ability to approach and communicate with patients in the clinical setting. In addition, students benefit from the opportunity to work with technologically sophisticated equipment such as clinical information systems and hemodynamic monitoring systems in the educational setting before encountering such equipment in the clinical setting.
Advanced practice nursing students benefit from high-fidelity simulations that are complex, realistic, and interactively challenging experiences that support them in developing and practicing leadership abilities, teamwork, and decision-making skills. With patient simulators, for example, students can practice complex assessment skills in their area of clinical practice. Faculty can create scenarios and program equipment to simulate serious clinical situations such as respiratory arrest or aberrant cardiac rhythms that may require an emergent response. Simulations are also appropriate to prepare psychiatric nurse practitioners. As students respond to these more complex situations, they demonstrate their abilities to establish priorities, make decisions, take appropriate action, and work successfully as part of a team (Reese, Jeffries, & Engum, 2010). Within the simulated environment, advanced students also can demonstrate application of learning because they are no longer merely acquiring knowledge and skills. Students learn from the simulated practice without the need for faculty stepping in to correct and control the situation. High-fidelity simulation affords all students the opportunity to experience a baseline set of clinical scenarios, including those that are uncommon or rare, and to practice skill sets repeatedly until they develop a routine and process for safe patient care (Reising & Hensel, 2014).
Simulations as a Teaching–Learning Strategy
Nurse educators have used low-fidelity simulation such as manikins, role play, and case studies as a teaching–learning strategy for decades. The introduction of high-fidelity simulation (in the form of affordable, portable, and versatile human patient simulators) in the late 1990s transformed health care education and is now one of the foundational strategies in the preparation of health care professionals not only for teaching, but also for assessment and evaluation, developing interprofessional team skills, and for clinical substitution and make up for missed experiences.
Simulations Used for Assessment and Evaluation of Learning
Given the widespread use of simulations, there is also the potential for using simulations for assessment and evaluation of student learning. Using simulation 309for assessment and evaluation of learning should be integrated into the larger process of planning, implementing, assessing, and evaluating learning. Faculty should identify the purpose of the assessment or evaluation early in the process to ensure the evaluation is relevant and evaluates the learning outcomes for which it is intended (Adamson, 2014). Although more traditional forms of assessment continue to be employed—for example, pretesting and posttesting using multiple-choice tests—simulation-based assessments are increasingly being used in the evaluation process, both in a formative manner, as part of an educational activity or training, or in a summative manner, as part of a graduation or certification process.
When simulations are being used for assessment or evaluation, the activities fall into two broad categories—“low-stakes” and “high-stakes” situations—depending on the significance of the evaluation (Boulet & Swanson, 2004). Low-stakes assessments are situations in which the simulation is used by the learner and faculty to mark progress toward personal, course, or program learning goals. High-stakes assessments include licensing and certification examinations, credentialing processes, and employment decisions (Jeffries, Hovancsek, & Clochesy, 2005). Simulation technologies used for assessment range from case studies and standardized patients (e.g., OSCEs) to haptic task trainers and high-fidelity human simulators.
As with any type of assessment, faculty must consider the issues of validity and reliability. For assessments in low-stakes or learning situations, construct and concurrent validity should be addressed. Construct validity is the degree to which an assessment instrument measures the dimensions of knowledge or skill development intended. Concurrent validity is determined by evaluating the relationship between how individuals perform on the new assessment (in this case a simulation) and the traditional (standard) assessment instrument. An assessment with high concurrent validity, for example, is one in which the learner’s simulator assessment score is comparable to his or her score when performing the same examination on a standardized patient scored by using a checklist.
Predictive validity is required for simulations used in assessments in which licensure, certification, or employment are at stake. Determining predictive validity in high-stakes assessment is a complex process. Predictive validity is the extent to which performance on a particular simulation predicts future performance, such as clinical decision making or psychomotor skills. Evaluating predictive validity requires that, in addition to current performance, the clinical skill or decision making of specific individuals be tracked over time. There has been little research and evidence-based information specifically focused on quantifying the effect of simulation-based assessment activities on student or practitioner learning.
Simulations also are being used to assess and evaluate students’ clinical skill competencies and clinical decision-making capabilities. Using standardized patients to assess the clinical skills of medical students and residents has become widespread (Chambers, Boulet, & Gary, 2000). OSCEs are clinical examinations that vary in format but mostly include a set period for the student to assess and interact with a standardized patient, an actor or actress hired to portray a certain type of patient with a specific diagnosis and clinical symptoms. Wilson, Shepherd, and Pitzner (2005) used the low-fidelity human patient simulator to acquire and then assess nurses’ health assessment knowledge and skills. The use of the low-fidelity manikins proved to be an effective tool to assess for health assessment skills. Miller, Leadingham, and Vance (2010) used the human patient simulator to meet learning objectives across core nursing courses.
When using simulations as an assessment mechanism, the nurse educator should also consider the improvement in the use of standardized patients, the sophistication of computer-based evaluation techniques, the use of newer physiologic electromechanical manikins, and the fidelity of immersive haptic devices. Because of these advances, nurse educators are now better able to assess learning, promote a better educational effort, improve academic courses and programs, and ultimately prepare students to provide quality, competent and safe patient care.
Simulations Used in Interprofessional Education
Conventionally, nursing and other health care education as a whole is delivered on a uniprofessional basis, eliminating the reality of everyday interprofessional collaborative clinical practice. IPE is bridging that gap (Alinier, Harwood, & Harwood, 2014). IPE can be defined as two or more professions that work together and learn from and about one another in an effort to improve collaborative 310practices and the overall quality of patient care (Newton, Bainbridge, & Ball, 2014). (See also Chapter 11.) In Canada, IPE to improve interprofessional collaborative practice has been documented for more than 50 years, but in terms of research, it has gained popularity in the last 15 years. Currently, most health education programs are beginning to embed IPE into their curricula, thus increasing attention to continuing professional development. There are many advantages of IPE, including breaking down both real and perceived barriers between different clinical aspects, enhancing interprofessional cohesiveness and awareness, and providing an opportunity to develop mutual respect among members of an interdisciplinary team. Within an interprofessional team, an important element of providing safe and effective patient care is knowledge and understanding of other professionals’ roles and skills (MacDonald et al., 2010). A study by Alinier et al. (2014) investigated the knowledge and perceptions of immersive clinical simulation in undergraduate health care IPE. The study showed that students acquired knowledge, became familiar with other professions, and developed a better appreciation of interprofessional learning even with limited interprofessional simulation experiences. During the debriefings, discussions highlighted the importance and value of interprofessional training by students, especially when well contextualized and facilitated through exposure to realistic scenarios. Even though it is widely agreed that collaborative practice among health care professionals improves quality of care and patient outcomes, evidence-based and innovative suggestions as to how this should be accomplished are lacking. Current literature is limited in providing strategies that foster interprofessional collaborative learning in an easily adoptable and implementable way. Additional research is needed in IPE to quantify its effects on theoretical and clinical practice applications and the ability for nursing students and the integration of novice nurses into clinical practice.
Simulations Used for Clinical Substitution and Clinical Make-up
Simulations are currently being used in clinical settings to substitute for real clinical time for various reasons. For some schools of nursing, the issue of finding quality, appropriate clinical sites is a challenge for faculty, particularly in specialty areas such as pediatrics or maternal health (Hayden, Kegan, Kardong-Edgren, & Smiley, 2014; Meyer et al., 2011). Nurse educators have substituted clinical time in many cases for time in the simulation area to provide nursing students appropriate clinical experiences that are developed and implemented through clinical simulations. In some instances, schools of nursing are labeling clinical times as “off-campus” clinical for actual experiences in health care institutions and “on-campus clinical” when the clinical experience is obtained in the simulation laboratory. At New York University, adult health courses are being delivered with 50% off-campus clinical (real clinical time) and 50% on-campus clinical to help with their clinical faculty shortage and competition for clinical sites (Richardson, Goldsant, Simmons, Gilmartin, & Jeffries, 2014).
In some schools of nursing, clinical simulations are being used for “clinical make-up” days for those students missing clinical because of illness, weather, or other unforeseen causes. There can be an entire “clinical day” set up in the simulation lab for clinical hours. Some nurse educators use virtual simulations (computer-based learning) that has a debriefing component and scoring to meet clinical make-up hours when needed and when the content fits with the curriculum needs.
A landmark multisite study done by the National Council of State Boards of Nursing (NCSBN) explored the clinical competency of new graduates on their transition to practice based on their participation in either a control group, a group that substituted 25% of real clinical hours for simulations, or a group that substituted 50% of their clinical hours for simulation (https://www.ncsbn.org/index.htm). The study report stated,
substantial evidence [demonstrates] that up to 50% simulation can be effectively substituted for traditional clinical experience in all prelicensure core nursing courses under conditions that are comparable to those described in the study. These conditions include faculty members who are formally trained in simulation pedagogy, an adequate number of faculty members to support the student learners, subject matter experts who conduct theory-based debriefing, [and] equipment and supplies to create a realistic environment. (Hayden, Smiley, Alexander, Kardong, & Jeffries, 2014, p. S38)
The NCSBN also stated that the State Boards of Nursing should feel assured about the validity 311of simulation programs if nursing schools have enough dedicated staff members and resources to maintain the program in an ongoing basis. These findings are significant for the nurse educator community because too often quality clinical sites are difficult to find; health care agencies are limiting the amount of practice and procedures students can actually perform in the clinical setting; and, the client census is diminishing in the acute care settings such that clinical experiences are limited and focus only on the acute care population.
Challenges and Benefits of Using Simulations
Simulations can offer nurse educators and health care providers a significant educational method that meets the needs of today’s learners by providing them with interactive, practice-based instructional strategies. Implementing and testing the use of simulations in educational practice has both challenges and benefits.
Most of the challenges of using clinical simulations center on educators’ preparation for using simulations and interprofessional simulations. Before using simulations as a learning strategy, the faculty must have:
1. A firm foundation in experiential learning
2. Clear learning objectives for the simulation experience
3. A detailed design taking into account that an educator facilitates learning (versus tells the learner)
4. Sufficient time for learners to experience the simulation, to reflect on the experience, and to make meaning of the experience
5. Faculty development in the area of simulation pedagogy; the teaching strategy is student-centered, which for many is a paradigm shift in teaching
6. Strategic ways to quantify and document clinical simulation hours towards licensure or certification
7. When using IPE simulation, there must be alignment of student clinical placements across the professions; preparation of all faculty and preceptors involved; commitment from all professions to making IPE experiences a priority; and adequate financial, human, and space resources. (See also chapter 11)
The benefits of using simulations include:
1. Active involvement of students in their learning process. By interacting with the simulation, examples, and exercises, the learner is required to use a higher order of learning rather than simply mimicking the teacher role model. Decision-making and critical thinking skills are reinforced through this teaching modality.
2. More effective use of faculty in the teaching of clinical skills and interventions. In a simulated experience, faculty members have an opportunity to observe students more closely and to allow students to demonstrate their potential more fully. The feedback or debriefing by faculty is a powerful learning tool.
3. Increased student flexibility to practice based on their schedules. The learner can access the simulation at his or her convenience and is not required to practice the skills in front of an instructor, although that option remains available for those who need extra instruction or reinforcement. The learner can revisit a skill several times in an environment that is safe, nonthreatening, and conducive to learning.
4. Improved student instruction. Student instruction is improved through better consistency of teaching; increased learner satisfaction in both the classroom and the clinical setting; the opportunity for safer, nonthreatening practice of skills and decision making; and a state-of-the-art learning environment.
5. Effective competency check for undergraduates, new graduates, or new nurses going through orientation. The simulation experience provides a competency check of the participants’ knowledge, skills, and problem-solving abilities in a nonthreatening, safe environment.
6. Correction of errors discussed immediately. Students can learn by being immersed in their learning experience and then being debriefed after the encounter on what was right and what needed to be done differently.
7. Standardized, consistent, and comparable experiences for all students. Educators can create consistent, standardized teaching activities so that all students in a clinical 312course can experience an important clinical event, assessment activity, or other essential clinical learning encounter.
8. Opportunities for collaboration and IPE. This provides an avenue for safe and effective patient care through knowledge and understanding of other professionals’ roles and skills that all students in a clinical course can experience.
As educators are incorporating simulations into their courses and into the nursing curriculum, major challenges and benefits have been noted. Faculty must consider both challenges and benefits as the simulation pedagogy is adopted into courses and the nursing curriculum.
Planning to Use Simulations
Using simulations as a teaching–learning strategy requires advance planning. Planning should consider the need for resources, the overall curriculum, preparation of the student, and faculty development.
Operationalizing simulation requires physical space and equipment, the use of different types of simulation equipment and technology (manikins, virtual reality, Skype, electronic health records), faculty, and support staff. The physical space must be large enough to accommodate teaching and learning space, office space for faculty and staff, storage space, debriefing space, and, if used, space for video recording. Well-resourced spaces may mimic an acute care setting or operating room suite. Resources also include support staff who assist faculty in managing the equipment, and supporting the audiovisual technology.
A needs assessment and analysis should be performed to understand the intricacies of the curriculum in general and how the specific courses intersect with each other. Examining specific course content and the clinical site placements gives a broad overview of the types of experiences students are exposed to and how objectives are met. Further examination of QSEN competencies, national patient safety goals, the NCSBN Licensure Examination blueprint, the Institute of Medicine Initiatives, and standardized testing results can help design and pattern content for simulation. In thinking who the learners are, why they learn, what they learn, and how they learn, a schematic design for each course can be developed to determine how the goals of theory, simulation, and clinical are interconnected and where simulation would be appropriate.
Preparing the Student
Simulation is likely a learning strategy that is a new experience for the student. Faculty must orient the student to the use of the equipment and to his or her role as an active and engaged learner. Students must understand the learning goals, what assignments they should complete or information to have at hand during the simulation, how the simulation relates to the reality of clinical practice, and the significance of the debriefing session. If the simulation is being used for assessment or evaluation, faculty must provide an opportunity for students to become familiar with the equipment, and make clear the rubrics that will be used to judge performance.
Simulation supports students’ learning needs in a variety of ways. For example, simulations may offer a flexible, accessible opportunity to practice skills and interventions when student schedules permit. The learner can access the simulation at his or her convenience and not be required to practice the skills in front of an instructor, although that option can remain available for those who need extra instruction or reinforcement. Simulations also offer an opportunity to practice a selected skill set a number of times in an environment that is safe, nonthreatening, and conducive to learning. Simulations also provide exposure to real-life clinical experiences for students before caring for a specific type of patient in a specific type of clinical setting, thus giving them confidence when in the actual clinical setting.
Educators prepared in the use of simulations are essential to the success of integrating simulations across the curriculum. However, unlike the traditional classroom setting, the faculty role when using simulations is no longer teacher-centered but rather is student-centered, with the educator assuming the role of a facilitator in the student’s learning process. The educator’s role during the simulation process varies, depending on whether the simulation is being conducted for learning or evaluation purposes. Educators must provide learner support as needed 313throughout the simulation and facilitate or guide the debriefing at the conclusion of the experience. If the simulation is being conducted for evaluation purposes, the teacher’s role changes to that of an observer and rater/grader.
When using simulations for the first time, faculty must feel comfortable with the simulations they are using. Pretraining on simulation pedagogy and debriefing is essential (National League for Nursing, 2015). Faculty may require assistance with simulation design, use of the technology, and setting up equipment for the activity. Whei Ming and Juestel (2010) found that novice faculty members needed assistance to operationalize the critical thinking learning objectives in a clinical simulation. To assist faculty, the educators developed a series of questions that provide direction about the specific thought processes involved in the application of the nursing process through the use of clinical simulations (Table 18-1).
Critical Thinking Learning Objectives and Core Questions to Ask in Clinical SimulationsCritical Thinking Learning ObjectivesCore QuestionsAssess client to collect relevant data.
• Identify cues and make inferences.
• Validate data.
• What are the possible problems in this situation that need to be solved? On what evidence have you based your inferences?
• Is your evidence valid? What factors may alter the accuracy of the data? How would you validate each item of evidence?
• Why are these items relevant? How are they related?Diagnose actual and potential client health needs.
• Are the clustered data sufficient to support each diagnosis? What additional data do you need?
• Cluster data.
• Draw diagnostic conclusions.
• Are there different possibilities for clustering these data? Are there other alternative diagnoses that may fit different ways of clustering?
• What other data are needed to rule these possibilities in or out?Plan care based on identified client health needs.
• Set priorities.
• What are the most important problems that need to be solved? On what criteria did you base your decision?
• Predict outcome criteria.
• Generate solutions (interventions).
• What are the expected outcomes of the problem?
• What are the possible interventions for the problem described?
• What are the possible risks and benefits involved in each intervention?Implement plan of care.
• Test solutions.
• When do you assess the client’s response to each intervention? What are the desired responses to the intervention?Evaluate progress toward attainment of outcomes.
• If an adverse reaction happened, what would you do next? Why?
• Perform a criterion-based evaluation.Self-critique thinking strategies used to reach decisions.
• What were the factors influencing your thinking?
• Self-regulate thinking.
• What would you do differently in a different situation?
From Whei Ming, S., & Juestel, M. (2010). Direct teaching of thinking skills using clinical simulation. Nurse Educator, 35(5), 197–204.
Schools of nursing have found it helpful to send faculty to an orientation course or develop their own orientation to develop faculty for using simulations in their teaching. These courses include information about designing and using scenarios, the role of the faculty, and how to conduct the debriefing. Faculty experience a simulation first-hand as they participate in these courses.
Simulations should be carefully planned. The process of designing, implementing, and evaluating a simulation to support learning in nursing education is best done using a systematic, organized approach. To help nursing educators and researchers in this 314developmental process, a simulation framework (Jeffries, 2005) has been developed to identify the components of the process and their relationship to guide the design, implementation, and evaluation of these activities.
The Simulation Model
A framework (Fig. 18-1) has been designed by a national group organized by the National League for Nursing to assist educators in outlining the first steps of simulation development to provide a consistent and empirically supported model to guide the design and implementation of simulations as well as the assessment of learning outcomes when using simulations (Jeffries, 2005, 2012). Within the framework, five design features for developing a clinical simulation scenario are described. A simulation template used as a guide to develop the clinical simulations can be found at the Simulation Innovation Resource Center (SIRC) website at http://sirc.nln.org/.Figure 18-1 Simulation model. Jeffries, P. R. (2012). Simulations in nursing education: From conceptualization to evaluation (2nd ed.). Philadelphia: Lippincott, Williams and Wilkins. (Used with permission.)
When developing the scenario, the design features are considered within the development process. For example, problem-solving components are considered in the scenario progression writing. Faculty can consider one or two problem-solving components designed in the scenario to be implemented by the novice students and three or four decision-making components for the more advanced student, perhaps to facilitate and emphasize prioritization at this level. After the simulation template is completed, it is advised that the scenarios be peer reviewed by content experts to ensure that evidence-based practices are being incorporated into the scenario and to confirm accuracy and that the content is up to date for today’s health care world. Finally, the scenario must be pilot-tested with targeted end users so that educators can ensure that the scenario is at the correct level for the learner and can review the scenario for sufficient decision-making points and cues to engage the students in the simulation. A variety of resources exist 315to provide educators with knowledge and skills on developing simulation scenarios, including regional and national workshops, conferences, instructor courses, and several publications (Campbell & Daley, 2008; Guhde, 2011; Jeffries, 2007; Simulation Innovation Resource Center [SIRC], n.d.).
Evidence-based Debriefing and Reflection
Debriefing is one of the key design features to consider when developing a simulation (see Fig. 18-1). Debriefing is a process by which educators facilitate learners’ reflection or reexamination of clinical encounters (Dreifuerst, 2009, 2012). Ideally, debriefing should be twice as long as the scenario and involves active participation from all learners (caregivers to observers), where the learners do most of the talking. The debriefing environment should be a safe environment where learners can engage in meaningful discussion. Debriefing in the context of simulation involves reflective observation and abstract conceptualization. Reflective observation has its roots in Gestalt psychology and in the works of Lewin (1951); Schön (1987); Diefenbeck, Plowfield, and Herrman (2006); and Kolb (1984). Kolb (1984) and others (Sewchuck, 2005; Svinicki & Dixon, 1987) suggest that the experiential learning cycle is a continuous process in which knowledge is created by transforming experience. Individuals have a concrete experience, they reflect on that experience (reflective observation), they derive meaning (abstract conceptualization) from the experience, and they try out or apply (active experimentation) the meaning they have created, thus continuing the cycle with another concrete experience. Debriefing encompasses the cognitive domain assessing knowledge; the kinetic domain assessing skill and action; and the affective domain, or how the learner felt or interacted with the patient or other staff.
The role of faculty in facilitating simulation exercises is to support participants in the reflection and debriefing process. Objectives of debriefing include the opportunity for the learners to describe what the experience was like for them; this includes a release of emotional tension about the experience, a guided review of the patient and objectives, the identification and sorting of thinking, and reinforcement of teaching and correction of misconceptions. Debriefing is an opportunity to reference real-life experiences, normalize behaviors, and acknowledge emotions.
Debriefing strategies are varied and several models are used in the simulation setting (Cheng et al., 2014; Simon, Rudolph, & Raemer, 2009; Waznonis, 2014). The National League for Nursing in its Vision Statement, Debriefing Across the Curriculum, recommends that faculty use evidence-based resources to develop their skills in debriefing (National League for Nursing, 2015). The Debriefing Assessment for Simulation in Healthcare (DASH) tool is designed to evaluate and develop the debriefing skills of the facilitator. This tool evaluates the facilitators’ ability to conduct debriefings following specific behaviors. It is an evidence-based tool designed according to how people learn and change in experiential learning and was vetted by an expert panel at Harvard (http://www.harvardmedsim.org/_media/DASH_Bibliography_2011.pdf). Table 18-2 depicts one debriefing model (Overstreet, 2010).
Components for Debriefing Nursing Students Using the Ee-ChatsDebriefing ComponentEducator Action/Activity/StrategyE—EmotionFaculty need to address learners’ emotions that have been stimulated during the simulation encounter; encourage the students to translate emotions into words.e—ExperienceFaculty can briefly share their experiences or stories; inform the students how the expert would have handled the situation—but be brief, this is only one small part of debriefing.C—CommunicationEducators should talk less and students more; students also can observe your verbal and nonverbal messages; the debriefing should be a positive experience.H—Higher Order of ThinkingStudents should be encouraged to reflect in, on, and beyond the simulation encounter they have experienced; how will this experience translate into the clinical one?A—Accentuate the PositiveEducators need to be positive when conducting a debriefing—reframe and rephrase your questions into inquiry-time ones, not blaming. Focus on behaviors that are professional and essential.T—TimeAllow students time to formulate their responses and reflections. Embrace silence.S—StructureDebriefing time should focus on the encounter, the events, actions, and behaviors demonstrated in the simulation.
From Overstreet, M. (2010). Ee-chats: The seven components of nursing debriefing. The Journal of Continuing Education in Nursing, 41(12), 538–539.
Facilitators face challenges in debriefing, including blame-setting for performance, statements such as “this wouldn’t happen in real clinical,” learners who are open with dislike about the learning environment, learners who are hostile and defensive or who are self-critical and defeated based on performance. Facilitators provide a safe, nonjudgmental environment and coach students to reflect on what they saw, heard, and experienced. All debriefings should be well planned and structured. The key for faculty during debriefing is not to provide more information or to lecture on the “correct” way or answer, but to guide students along the path of reflection. Open-ended questions, silence, and pauses help elicit feedback from learners and encourage active participation. Identification of a “take-away” message or transfer of learning to other situations should be included (Lusk & Fater, 2013).
Once the simulation is designed, faculty members are ready to implement it into the nursing course. The following guidelines may be useful to educators implementing simulations into their nursing courses:
1. Make sure specific objectives match the implementation phase of the simulation. When faculty design a simulation, the objectives and nature of the simulation should be clearly defined for the students and facilitator. Furthermore, if the simulation is designed, for example, around the care of an 316insulin-dependent patient, then the scenario should be created using problems typically encountered and the problem-solving skills needed for that patient’s care. The simulation should focus on the objectives and not on potential co-morbidities or extraneous issues.
2. Set a time limit for the simulation and the debriefing encounter and then adhere to it. Too often instructors observe that in simulations students are immersed for a specific time limit but are not able to accomplish all of the assessments and interventions the instructor had desired. At times instructors may let the scenario proceed beyond the specific time frame; however, if the simulation is scheduled for 20 minutes, the encounter needs to be 20 minutes. If students do not achieve the objectives desired, the reflective observation time can be spent on their experiences and the meaning they make of them.
3. Implement an appropriate orientation of students to the simulation labs where they will be interacting with the simulators. This is an important step to help eliminate the anxiety and fear of the unknown associated with initial exposure to simulation as a whole. It is also important to engage in a confidentiality agreement with the students that makes debriefing a safe environment for students and faculty, and lastly, implement a fiction contract where students are expected to treat the simulation environment as they would a true clinical encounter.
4. In undergraduate nursing programs, it is advisable to make assignments so students know their specific roles during the simulation. Unless developing or testing team leadership skills, students need roles (e.g., nurse, observer, family member) assigned before encountering the simulation to bring organization to the experience. If roles are not assigned, students waste time trying to decide what role to play. In advanced practice nursing programs, role delineation may be handled by the students. It is conceivable that advanced practice nurses can come together to determine specific roles and responsibilities. This may also be a good topic to investigate during postsimulation debriefing.
5. Avoid interrupting the simulated encounter when students are trying to problem-solve on their own. In simulation, the learners function as professionals, not as students, so they are asked to step beyond their comfort zone and interact in the scenario without someone directing them how to act. Facilitators should observe a simulation remotely, either behind a one-way mirror 317or via closed-circuit television, so students cannot see facial expressions, hear comments, or see nonverbal gestures. It is best for faculty to discuss the points of concern, prioritization, and problem-solving issues during the debriefing immediately after the simulation event. If this is not done in the immediacy of the simulation, the behaviors can be forgotten or confused with other scenarios.
6. Involve a limited number of learners in the simulation experience in addition to one or two observers or recorders of the encounter. Typically, two to six students are each assigned a role in the simulation experience. The roles within the simulation need to be identified before and recognized during the simulation. For example, students can wear name tags or labels and appropriate clothing for particular roles or have certain props available to help delineate the roles. When an educator has more students than are needed to participate in the simulation, these students can be assigned an observer role.
7. Ensure that the simulation is appropriate for the learners’ skill levels and cognitive ability. Although a prominent design feature when developing simulations is fidelity, simulations need to be realistic to the degree that matches the learning level of the student group. Early on in exposure to the simulation environment, students benefit from scenarios that are comparable to their didactic learning. Low- or medium-fidelity manikin and standardized patients with basic care needs offer opportunities to focus on basic skill and knowledge acquisition. Failure and anxiety in the simulation scenario can occur when the simulation objectives include skills or competencies students have not learned (e.g., IV management prior to IV curriculum or altered cardiac or lung sounds prior to cardiac or lung modules). As exposure to the simulated environment increases, learners benefit from a higher level of complexity and a mix of fidelity, including challenges found in a complex environment such as simulated emergent events that involve critical thinking, active interaction, teamwork, and collaboration with the health care team to achieve a common goal. Simulations assist students at the application level of learning to practice their decision-making, problem-solving, and team member skills in a nonthreatening environment. The environment needs to be sufficiently realistic to allow for suspension of disbelief, so that the transition of knowledge from theory to practice can be stimulated. In simulation there is no “pretend.” All necessary equipment should be available and standards and protocols should be followed to mimic the clinical setting. If a patient is to take a medication, the proper steps for administration should be used.
8. When planning to incorporate simulations into the course or curriculum, ensure that faculty development is included in the planning. Faculty need to know how to conduct a simulation and a debriefing session to achieve the desired outcomes with the teaching–learning strategy. Faculty need to be prepared to design and conduct simulations in the educational setting before they are actually placed in the learning laboratory or clinical practicum with students in a simulation situation. All faculty members using this type of strategy in their classroom or clinical instruction need to be aware of and clear about the purpose of the simulation activity. At the end of the simulation, a clear summary and highlights need to be included by all instructors, particularly if there are several educators using the same simulation in a course. Discussion about simulations and how to implement them and clarity on learning outcomes for the simulation are needed and must be agreed on by faculty before implementation of the simulation. Clear delineation of the objectives of the scenario and the debriefing model should be followed by all facilitators. A predesigned concept map for each scenario can help guide facilitators for consistent debriefing.
Integrating Simulations into Courses and Curricula
Simulations can be integrated into nursing courses, laboratory experiences, and clinical courses to promote more active and experiential learning at 318most schools of nursing (Katz et al., 2010). As more schools adopt clinical simulations in their courses and curricula and as actual clinical experiences are becoming more difficult to obtain, some faculty and their state boards of nursing are supplementing or substituting clinical time with simulations.
More recently, following the trend in electronic communications for teaching and students’ strong acceptance of online learning, more sophisticated technologies have enabled simulation approaches to transition from the classroom to a virtual platform.
Virtual simulation in online nursing education combines the pedagogy of face-to-face simulation with electronic multimedia options to produce activities that are both interactive and mediated by the learner. Virtual simulation programs can be hosted online and accessed using a choice of navigable software using learning objectives that vary from highly focused technical skills training to broader, case-based patient scenarios that require critical thinking and clinical decision making (Cant & Cooper, 2014). Some popular virtual simulation software products available for online nursing education include ArchieMD, CliniSpace, Second Life, TINA, Virtual Heroes, and vSim.
Faculty have integrated simulations in a variety of courses. Thomas, Hodson-Carlton, and Ryan (2010) used clinical simulations in a senior leadership course to better prepare and facilitate new graduates to clinical practice. Clinical scenarios were developed that incorporated students, faculty, staff, and community volunteers who role-played situations that students may encounter after graduation. Some of the issues embedded in the scenarios include staffing problems, physician interactions, patient and family communications, and crisis interventions.
Hamilton (2010) used clinical simulations during academic and clinical experiences to equip students with the skills necessary to productively cope with the stressors faced in difficult end-of-life situations. Using the End-of-Life Nursing Education Consortium materials, the educator found simulations to be an effective teaching strategy to identify anxiety levels prior to clinical experience and as a venue for exploring learning and coping styles.
Maternity simulators have been used to teach students about maternal and child health. Undergraduate faculty from a large Midwest nursing program implemented a 6-hour laboratory and virtual clinical experience for students in the maternal–newborn health rotation that incorporated various simulations (Bantz, Dancer, Hodson-Carlton, & Van Hove, 2007). This experience consisted of eight stations, including assessment of the postpartum fundus, newborn assessment and care (with a SimBaby), newborn nutrition, labor, and birth (with the Noelle birthing simulation manikin), fetal heart rate assessment and interpretation, Leopold’s maneuvers, and computerized charting. According to Bantz et al. (2007), the majority of students who participated in this clinical laboratory experience indicated that they felt better prepared to provide nursing care to newborns and their mothers in the clinical site.
DeBourgh and Prion (2010) used a quasiexperimental pretest and posttest study of 285 prelicensure students to teach students fall prevention and patient safety using clinical simulations with standardized patients. The results of the teaching and research conducted concluded that the simulation learning experience provided students with knowledge and skill gains they could apply to clinical practice.
Thompson and Bonnel (2008) integrated the use of high-fidelity simulation in an undergraduate pharmacology course to provide an applied learning experience where students could make connections between learned content and clinical application. An experience of safe medication administration has been added to both pharmacology course simulations and any simulation in which the “patient” is to receive medications.
Rosenzweig, Hravnak, and Magdic (2008) developed a patient communication simulation experience for the acute care nurse practitioner students at a major university to evaluate students’ perceived confidence and communication effectiveness before, immediately after completion, and 4 months after completion. Results showed that the content and methods used for the simulation experience improved students’ confidence and perceived skill in communication in difficult acute care situations.
As distance education course formats proliferate in nursing curricula, simulation has been recognized as a potentially rich learning strategy. Nelson and Blenkin (2007) used online role-play simulation to provide students with the opportunity to learn professional and personal relationships in an online environment. The online learning platform provided students with a learning opportunity to deal with difficult behavior and to manage violence, abuse, and patients with dementia. To initiate the learning activity, the authors built what was called a “kickstart” episode, in which students would have to react to a significant 319event, for example, a patient dying. Participating students logged in and played their assigned roles, which ranged from long-term care residents to facility staff members. During the computer-based event, students role-playing as health care professionals could enter into an “interaction space (ispace)” where a threaded discussion could occur about the patient’s problem. Several resources were available to students within the online simulation environment, including instruction sheets and video clips to assist the students with the care of these selected patients. Students immersed themselves in the online simulations and believed that the level of realism paralleled clinical nursing practice and offered a relevant student learning experience.
Unfolding case simulations are gaining more attention in nursing programs. Durham and Sherwood (2008) used unfolding simulated cases to teach quality and safety concepts and how these concepts are integrated into nursing practice. In addition, Batscha and Moloney (2005) used online unfolding case studies to facilitate nursing students to analyze, organize, and prioritize in novel situations. Finally, Azzarello and Wood (2006) suggest that unfolding cases can be used to evaluate students’ changing mental models because they offer a practical strategy for revealing flaws in students’ problem solving that would otherwise not be obvious. Unfolding cases are not limited to the traditional simulation laboratory. Innovative use of unfolding cases has the potential to transform traditional teacher-centered classrooms into interactive, engaging learning environments that support the flipped classroom (Educause Learning Initiative, 2012). The notion of the unfolding cases fit very well when teaching in the connected and “flipped” classroom (see Chapter 19).
Evaluation Considerations when Using Simulations
Evaluation of the Design and Development Phase of Simulation
To evaluate the design and development of simulations created by nurse educators, Jeffries (2005) developed the Simulation Design Scale (SDS). The purpose of this tool is to provide the educator with information and feedback that can be used to improve the simulation design and implementation. The SDS is a 20-item tool that the learner completes after participating in a simulation to provide feedback on whether the intended simulation design features were present. These features include the objectives and information, support, problem solving, feedback and debriefing, and fidelity. These are referred to as simulation design features because they define what a quality simulation requires if it will have a positive effect on learning outcomes. Content validity of this instrument was determined by a panel of nine nurse experts. Cronbach’s alpha was computed to assess internal consistency reliability for each scale. The coefficient alpha for the overall scale was 0.94. Table 18-3 briefly describes the SDS’s five components.
Simulation Design Scale ComponentsConcept and Design FeaturesDescription of ConceptInformation/objectivesClear objectives and timeframe for the simulation is information needed by the student before the simulation begins.Problem solving/complexityThe simulation needs to be designed with problem-solving components embedded in the written scenario or case. The level of problem solving needs to be considered; for example, use simple tasks and decisions if students are in a fundamentals course versus more complex tasks if students are in an upper-level course and are 6 months away from graduating.Student support/cuesStudent support in a simulation is offered before, during, and after. Support includes providing information and direction to the student before the simulation.FidelityA simulation should be as close an approximation as possible to the real event or activity that is being modeled to promote better learning outcomes.Guided reflection/debriefingGuided reflection reinforces the positive aspects of the experience and encourages reflective learning, which allows the participant to link theory to practice and research, think critically, and discuss how to intervene professionally in very complex situations.
From Jeffries, P. R. (2007). Simulations in nursing education: From conceptualization to evaluation. New York: The National League for Nursing. (Used with permission.)
Evaluation of the Implementation Phase
When simulations are implemented, particular components need to be included to ensure good learning experience, student satisfaction, and good learner performance. According to Chickering and Gamson (1987, 1991), incorporating the Principles of Best Practice in Education assists educators to implement quality teaching activities and improve student learning. As a component of the simulation model (Jeffries, 2005), those educational practices are considered very important in the implementation of simulations in the students’ learning environment. To measure this component, the Educational Practices in Simulation Scale (EPSS) was developed. The EPSS is a 16-item tool that the learner completes after a simulation. This tool measures whether the best practices in education, according to Chickering and Gamson (1987), are being used in the simulation. All seven educational practices in simulation are being evaluated; however, after conducting a factor analysis on the scale, four factors were identified and several of the factors were collapsed into these four components of the scale. Therefore the elements being evaluated in the EPSS are active learning, diverse ways of learning, high expectations, and collaboration, as shown in Table 18-4. The questionnaire was tested for validity and reliability. Content validity was established through a review by nine nursing experts. The coefficient alpha was 0.92.
Educational Practices in Simulation ScaleComponents of the EPSSDescription of Components within the ScaleExamplesActive learningThrough simulation, learners are directly engaged in the activity and obtain immediate feedback and reinforcement of learning. Learning activities can range from simple to complex.A case scenario in which an intubated patient is restless, agitated, and coughing, affecting his oxygenation status. Students can be asked to select the most appropriate intervention and describe the rationale for the intervention.Diverse styles of learningSimulations should be designed to accommodate diverse learning styles and teaching methods and allow students and groups with varying cultural backgrounds to benefit from the experience.Design a scenario that has visual, auditory, and kinesthetic components.High expectationsHigh teacher expectations are important for the student during a learning experience because expecting the student to do well becomes a self-fulfilling prophecy.Set up a scenario with multiple patient problems to challenge the learner and to advance learning and skill application to the next level.CollaborationCollaboration is pairing students in a simulation to work together. Roles are assigned so that students jointly work on the problem-solving and decision-making skills within the simulation together.Assign a student the role of a primary nurse and a third-year medical student the role of a physician. Place the two students in a setting where they will be confronted with a patient having postoperative complications that requires quick assessments and efficient decision-making skills to intervene appropriately with the patient.
From Jeffries, P. R. (2007). Simulations in nursing education: From conceptualization to evaluation. New York: The National League for Nursing. (Used with permission.)
Evaluation of Learning Outcomes
As discussed previously, learning outcomes can be measured through low-stakes and high-stakes simulations. Outcomes are defined for the learning activity and can be measured by a well-designed clinical simulation. Research in this area is growing as educators measure the outcomes of the simulation activity desiring to close the knowledge and skills gap within academe and practice. Some instruments available for evaluation include the Laseter Clinical Judgment Rubric (Laseter, 2007) and the Seattle University Evaluation Tool, and the Creighton Evaluation Instrument (Hayden, Keegan, Kardong-Edgren, & Smiley, 2014). Limited valid and reliable grading checklists for the evaluation of high-stakes simulation exist. Scoring checklists are an emerging area of research in simulation 321pedagogy that have been developed and tested for validity and reliability; an example is a checklist for use during perioperative emergency simulation training (McEvoy et al., 2014). Evaluation tools for clinical simulation training are evolving.
Educators use simulations to enhance learning outcomes and promote safe patient care environments. Nursing organizations, commissions of higher education, accrediting bodies, academic institutions, and schools of nursing are seeking answers to questions about simulation design and development, teaching and learning practices, implementation processes, and associated learning outcomes. Educators and researchers must join forces to develop more rigorous research studies testing simulation outcomes. National, multisite simulation studies by nurse educators are currently being conducted to enhance understanding of the educational usefulness of nursing simulations. For example, when simulations are used as a teaching–learning intervention, are learning outcomes improved? When developing a simulation, what are the important design features of a well-executed simulation in nursing education? How can simulations be used to prepare for or replace clinical experience? How does the use of simulations contribute to advancing nursing into the next generation? Educators need to make certain they are informed about the possibilities of simulations, their usefulness in enhancing student education, and the progress of educational research efforts conducted to develop and test new models of using simulation in nursing education.
Reflecting on the evidence
1. What evidence is available on the effectiveness of using simulation in support of learning?
2. When using a simulation framework, how would you construct a research project to test the framework?
3. Identify three research questions that might be addressed when studying reflective observation.
4. What is the optimal balance of simulated versus actual clinical practice in nursing education?
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Teaching in the Clinical Setting*
Paula Gubrud, EdD, RN, FAAN
The health care system is ever changing and the Patient Protection and Affordable Care Act (PPACA) (Patient Protection and Affordable Care Act, 2014) challenges faculty to prepare students for future roles and to practice in a health care system that is patient-centered, wellness-oriented, community- and population-based, and technologically advanced. Clinical settings within a variety of health care systems have also become highly complex. Clinical learning occurs in actual health care environments and laboratory settings where students apply their acquired knowledge and skills as they think critically, make clinical decisions, and acquire professional values necessary to work in the practice environment. The purpose of this chapter is to describe the environments for clinical teaching and learning, how the curriculum relates to clinical teaching, roles and responsibilities of clinical teachers, and teaching methods and models that facilitate learning in clinical environments.
Practice Learning Environments
The environment for practicum experiences may be any place where students interact with patients and families for purposes such as acquiring needed cognitive skills that facilitate clinical reasoning and decision-making as well as psychomotor and affective skills. The practicum environment, also referred to as the clinical learning environment (CLE), is an interactive network of forces within the clinical setting that influence students’ clinical learning outcomes. The environment also provides opportunities for students to integrate theoretical nursing knowledge into nursing care, cultivate clinical reasoning and judgment skills, and develop a professional identity (O’Mara, McDonald, Gillespie, Brown, & Miles, 2014). The CLE introduces students to the expectations of the practice environment, as well as the roles and responsibilities of health care professionals. To accomplish these outcomes, a variety of experiences are required in multiple settings. These settings may be special venues within schools of nursing or within acute care settings or communities. It is essential that practice environments be supportive and conducive to learning so that students will develop the qualities and skill abilities needed to become competent professionals (O’Mara et al., 2014). The following section describes these settings. Included among these are practice learning centers such as learning labs, acute and transitional care, and community-based environments.
Clinical Learning Resource Centers
To foster a nonthreatening and safe learning environment, the practice learning center is used at several stages of students’ learning. These centers encourage guided experiences that allow students to practice and perfect a variety of psychomotor, affective, and cognitive skills such as critical thinking and clinical reasoning before moving into complex patient environments. Simulation is one example of a teaching method used in the practice learning center. This method is increasingly used to evaluate knowledge acquisition as well as skill sets (Jeffries, 2014).
According to the National Council of State Boards of Nursing (NCSBN, 2005), “simulation is a teaching strategy used to validate the complex and comprehensive skill required of health care professionals.” 283Simulation-based learning is designed to replicate the reality of the clinical environment to provide participants with opportunities to practice and refine clinical reasoning, skilled procedures, and interprofessional collaboration. Schiavenato (2009) also states, “The human patient simulator (HPS) or high-fidelity mannequin has become synonymous with the word simulation in nursing education” (p. 388). The explosion of simulation as a standard clinical learning activity is evident in the literature and a recent multisite study validates the use of this modality in clinical education (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). This study included 10 prelicensure sites and used a three-group quasiexperimental research design. The control group had traditional clinical experiences with no more than 10% of their time spent in simulation. One experimental group had 25% of their clinical time in simulation, and the other experimental group spent 50% of their clinical time in simulation. The study began with the first clinical courses and used multiple measures to assess participants’ nursing knowledge and clinical competency throughout the entire program of study. Study participants also rated how their learning needs were met in both simulation and in the clinical environment. Study results found no significant differences between all groups among assessment measures. The study validates simulation as high-quality clinical learning experience that can be used to replace a significant number of traditional clinical hours.
Virtual Clinical Practica
Given the challenges of finding sufficient clinical experiences for students, faculty are exploring the use of virtual clinical experiences made possible by online technologies that can create virtual clinical environments (Knapfel, Moore, & Skiba, 2014) and use existing technologies such as electronic intensive care units and telehealth capabilities to create opportunities for clinical experiences focused on providing opportunities to practice critical thinking, clinical reasoning, communication, and teamwork as a member of the interprofessional team (Sepples, Goran, & Zimmer-Rankin, 2013). The virtual clinical practicum (VCP) is designed to provide a live clinical experience to nursing students from a distance. Students gain clinical experience and practice skills and clinical judgment using telehealth technologies in which students observe a nurse taking care of a patient in a clinical setting without going to the actual clinical site, or as a registered nurse in masters doctoral programs who are learning to provide the care. The students can interact with the nurse, other members of the interprofessional team, and the patient using telehealth technology. The VCP process is developing as a potential solution in response to limited clinical practice sites as well as limited clinical experts, and for specific populations such as acute care pediatric patients. VCP provides needed clinical learning opportunity, especially in rural areas. (See Chapter 21 for further discussion of virtual environments.)
Acute and Transitional Care Environments
Acute and transitional care environments provide clinical experiences for undergraduate and graduate students preparing for advanced practice roles. Experiences in these environments enable undergraduate students, in particular, to exemplify caring abilities and practice the use of cognitive, psychomotor, and communication skills as they interact with patients and their families. These environments have become increasingly complex. A recent multisite study found that the complexity relates to factors such as extensive use of technology (e.g., electronic health records), rapid patient and staff turnover, high patient acuity, and complex patient needs (McNelis et al., 2014). These sites are suitable for learning experiences that focus on providing care in complex clinical settings, but faculty must consider the level of the student, the focus of the experience and the increased risk to patient safety when students have clinical assignments in these units.
Clinical Cases, Unfolding Case Studies, Scenarios, and Simulations
Simulated experiences that provide opportunities for students to integrate psychomotor, critical thinking, and clinical reasoning decision-making skills are equally valuable in assisting students to critically evaluate their own actions and reflect on their own abilities to apply theory to practice. The use of the high-fidelity HPS is one example of using realistic scenarios to prepare students for clinical experiences, substitute for unavailable or unpredictable clinical experiences, or enhance clinical experiences in a safe environment. The use of HPS helps transition the student from the classroom to the practicum environment. Students’ learning with the HPS method can be enhanced, patient care can 284be optimized, and patient safety can be improved. Additional benefits may include enhanced learning in a risk-free environment, promotion of interactive learning, repeated practice of skills, and immediate faculty or tutor feedback. (See Chapter 18 for additional discussion.) Cases, unfolding case studies, and scenarios are lower fidelity strategies but are equally helpful in preparing students for clinical experiences and bridging the gap between classroom and practice (Benner, Sutphen, Leonard, & Day, 2010; McNelis et al., 2014).
The health care delivery system and implementation of the PPACA is continuing to shift nursing practice from acute care hospital environments to the outpatient and community settings. These changes have resulted in care provided through the medical home model (Henderson, Princell, & Martin, 2012) and an increased use of community agencies such as ambulatory, long-term, home health, and nurse-managed clinics; hospice; homeless shelters; social agencies (e.g., homes for battered women); physicians’ offices; health maintenance organizations; and worksite venues and summer camps.
The use of technology such as video conferencing, wireless remote communication, information systems, and online courses has made it possible for clinical experiences in a community-based environment to occur at a distance. The transition to community-based teaching requires the faculty to ensure that learning opportunities available in the clinical placement allow the student to achieve the learning objectives. Faculty must adapt clinical learning experiences and incorporate skills used to develop competency with new technology and modify teaching methods (Bisholt, Ohlsson, Kullén Engström, Sundler Johansson, & Gustafsson, 2014). Additionally faculty must adapt to methods of clinical supervision such as being accessible by mobile phone and texting.
Establishing appropriate and sufficient learning experiences in the community may be difficult and challenging. These challenges often relate to economic constraints and the changes in nurse staffing patterns, with a resultant lack of time for professionals to facilitate skill development and serve as role models. These challenges may require faculty to be creative in their use and selection of resources within these environments and to consider establishing partnerships with the service agencies. Using community-based settings creates opportunity for critical thinking, understanding the health care system, and development of communication skills. Faculty can provide other experiences using simulation or the clinical learning laboratory to assist students to develop proficiency in skills traditionally performed in the acute care setting.
Learner-Centered Clinical Education Environment
Every health care environment and specific unit within these environments has a culture. The culture of the immediate environment affects teaching and learning (O’Mara et al., 2014). For example, the culture or patterns of actions and behaviors of the health care professionals can be observed in their attitudes, interactions, teamwork, and commitment to quality and safe patient care. Staffing levels, acuity of patients, anxiety of staff, and workload can influence these actions and behaviors. These aspects of the culture of the environment can in turn influence the time staff has to devote to students. The culture of the environment may also result in behaviors related to lateral violence. Lateral violence is often observed, witnessed, and verbalized by students. These verbalizations provide an opportunity for faculty to implement strategies and assist students with processing what they may be seeing, hearing, and feeling, and thus lessen the effects of these behaviors on students’ learning. For example, faculty can hold debriefing sessions, listen to students’ perceptions, and make concerted efforts to balance students’ feelings and thoughts by using appropriate strategies to soften, yet not deny, the reality of the culture.
Selecting Health Care Environments
Regardless of the practice environment, faculty are responsible for selecting appropriate CLEs within health care agencies and other organizations such as schools and social service agencies. Faculty must be aware of what particular systems are in place within the program to negotiate contracts that are congruent with the philosophies of the school of nursing and the agency, as well as those that specify the rights and responsibilities of both. Determinations must be made about regulation and accreditation status, adequacy of staff, the patient population for needed experiences, expected course outcomes, and whether or not the practice model is compatible for intended uses and curriculum needs. In addition, the 285adequacy and availability of physical resources (e.g., conference space) for students and faculty should be determined. Finding a practice environment that meets all specified needs is becoming a challenge because of factors associated with the delivery of health care. For example, rapid patient turnover often means faculty have to select available patients rather than those that best meet students’ learning needs. This limitation in patient availability can create opportunities for faculty to be creative in the manner in which learning experiences are selected and teaching strategies used. Regardless of the limitation, the role of the faculty is to assist students in making learning connections focused on application of content presented in the classroom to clinical practice. Dual clinical and classroom assignments for faculty may assist in making those necessary connections between clinical and classroom. “The very strength of pedagogical approaches in the clinical setting is itself a persuasive argument for intentional integration of knowledge, clinical reasoning, and skilled know-how and ethical comportment across the nursing curriculum” (Benner et al., 2010, p. 159). Thus faculty have a significant role in helping students to make the necessary connections between clinical and classroom experiences as they learn to think and act like a nurse (Tanner, 2002), in spite of limitations for clinical learning in the health care environment.
Building Relationships with Personnel within Health Care Agency Environments
The ability of the clinical faculty to facilitate students’ learning can be enhanced when an effective working relationship is established within the clinical agency. Effective relationships begin with effective communication, which must be practiced in an ongoing manner to maintain relationships and facilitate learning (Dahlke, Baumbusch, Affleck, & Kwon, 2012). This requires having an understanding of the environment and the roles of the individuals within the environment, adapting teaching approaches to the situation, and establishing relationships aimed toward enhancing the educational experience. These elements do not exist in isolation but are patterned to dovetail with or complement other roles. Information should be shared continually, clearly, and consistently about goals, competencies, and expected outcomes; the level of students; practice expectations; the clinical schedule; and related information. Such information enables staff to assist with identification of appropriate experiences for students.
Inasmuch as clinical faculty have the primary responsibility for teaching and guiding students in the clinical environment, others often assist in the process. Therefore the sharing of expectations with the staff is critical. Ensuring an orientation to the practicum environment and having students engage with staff early in the clinical experience promote positive student–staff interaction and provide opportunities for role clarification and the development of collegial relationships. A consistent demonstration of awareness of the mission and values of the agency through actions that are inherently respectful is crucial. Follow-up communication provides an avenue for those within the practice environment to keep abreast of changes.
Clinical Practicum Experiences across the Curriculum
Understanding the Curriculum
The curriculum, composed of a series of well-organized and logical entities, guides the selection of learning experiences and clinical assignments, organizes teaching–learning activities, and informs the measurement of student performance. The manner in which the curriculum is organized guides the planning of learning experiences in a logical, rational sequence. The curriculum is designed to build on prior knowledge and to reinforce the application of learning. While this description of curriculum relates to process, this does not preclude faculty’s use of creative and innovative methods in clinical environments. Creative methods have a high potential to motivate students and facilitate construction of knowledge to be applied in practice. Studies focused on perceptions of both clinical instructors and students indicate understanding the whole curriculum is a critical aspect of clinical instruction (Bisholt et al., 2014; Dahlke et al., 2012; Wyte-Lake, Tran, Bowman, Needlemann, & Dobablian, 2013). As students progress and engage in varied practicum experiences, it is faculty’s responsibility to interpret the curriculum and to describe the relationships between course competencies and practicum experiences.
Understanding the Student
Clinical experiences provide opportunities for students to practice the art and science of nursing, which enhances their ability to learn. To maximize these 286experiences, faculty must have full knowledge and understanding of each student (see also Chapter 2). The nursing student population is culturally diverse and includes members of varied age groups, many ethnic and racial groups, and an increasing number of men. This population is also likely to include persons with (or without) prior degrees from a variety of disciplines, as well as those who possess many different health care experiences and technological skill levels. In addition, students differ in their learning styles, levels of knowledge, and preferences for learning experiences; therefore faculty must make concerted efforts to balance the students’ learning needs, interests, and abilities when selecting clinical experiences without losing sight of the curriculum and expected competencies and outcomes. Such action can be facilitated by making an assessment of the knowledge, culture, and skills of the learner. Such an assessment helps the faculty determine whether students possess the cognitive, critical thinking, clinical reasoning, decision-making, psychomotor, and affective skills needed for the experiences.
Understanding the Clinical Environment
The clinical environment has been described as a place where students synthesize the knowledge gained in the classroom and make applications to practical situations. Chan (2002) describes the CLE as “the interaction network of forces within the clinical setting that influences student learning outcomes” (p. 70). A number of forces affect expected learning outcomes, including the availability of staff for supervision and coaching, and the degree of student-centeredness exhibited by the clinical teachers (Chan, 2002; Newton, Jolly, Ockerby, & Cross, 2012). Additionally, opportunities available for students to pursue individual learning outcomes define the effectiveness of the clinical environment (Newton et al., 2012). The extent to which the clinical environment values nurses’ work and provides an adaptive culture that embraces innovation, creativity, and flexible work practices also are important aspects that set the stage of effective learning (Newton et al., 2012). These forces, coupled with the need to adjust to an environment that requires an integration of thinking skills and performance skills, often result in increased anxiety among students. Creating a supportive clinical environment involves comprehensive orientation of students to the environment, ensuring they are prepared to perform necessary skills and encouraging creative and critical thinking (Ganley & Linnard-Palmer, 2010). Creating an environment where students are expected to succeed also reduces student anxiety (Ganley & Linnard-Palmer, 2010).
Traditionally, clinical rotations have consisted of short blocks of time spent on a unit caring for a patient or two, mostly performing nursing skills with little or no time dedicated to focus on integration of theory, application of critical thinking, and clinical reasoning. Often there is minimal focus on providing feedback or effective evaluation of the interventions performed. Additionally, the focus of the CLE is often focused on the operational aspects of the unit. Nursing staff are expected to meet productivity goals and are caring for patients that are extremely ill with multiple health care needs in complex and dynamic organizations. Nurses intuitively want to be good role models and nurture students but often do not have the time to do so. Faculty must balance the operational needs of the unit with the importance of ensuring that students receive feedback and have the opportunity to focus on daily learning goals related to clinical course outcomes.
Regardless of location of the practice setting, faculty and staff should provide an environment in which caring relationships are evident. The clinical practice environment should be a place where students feel that they are accepted and their contributions are appreciated by individuals with whom they interact (Chan, 2002). Attributes of staff such as warmth, support in obtaining access to learning experiences, and willingness to engage in a teaching relationship are considered helpful.
Selecting Clinical Practicum Experiences
Practicum experiences refer to all activities in which students engage in the practice of nursing. Such experiences are essential for knowledge application, skill development, and professional socialization. Practicum experiences are selected and planned to provide students with opportunities to work across settings and manage care for varied populations with emphasis on applying theory content from the classroom to the clinical experiences. Clinical experiences should include an emphasis on the nursing roles related to health promotion and disease prevention. Selection of practicum learning experiences requires all faculty to be knowledgeable about clinical education and have a sound understanding of the curriculum, the learners, and the learning environment.
The practicum experiences should also help students prepare for outcomes in a progressive, developmental manner. Experiences with patients from diverse populations and with different levels of wellness should be provided. Faculty should take advantage of opportunities to use their creative talents, clinical skills, and expertise to ensure that all students have opportunities to interface virtually or directly with a variety of patient populations.
As faculty begin to plan the clinical experience, it is essential to determine the goal of the particular clinical experience for that day. For the beginning student, focused clinical experiences in which the student is to focus on specific objectives and to achieve specific competencies incorporating individual learning needs requires faculty to create focused, goal-oriented learning activities (Gubrud-Howe & Schoessler, 2009). In a focused clinical learning activity, instead of providing all required care for one or two patients, students can focus on becoming proficient at a particular skill by practicing that skill for several patients. For example, students may interview several patients to work on communication skills, perform vital sign assessments on multiple patients to develop this particular skill set, or focus on learning standards of care in a specialty area. Organizing learning experiences allowing students to assign and delegate care or give and receive reports are other examples of focused clinical learning activities. The purpose of focused clinical learning is to design clinical learning experiences focusing on repetitive practice related to a particular skill set. Focused experienced should integrate students’ individual learning needs and focus on course outcomes.
Other learning goals may emphasize facilitating students’ ability to synthesize information, integrate didactic and clinical knowledge, develop clinical reasoning and judgment skills, and plan care for groups of patients (Benner et al., 2010; Tanner, 2010). Here, assignments that involve planning care for patients with complex needs and for multiple patients are appropriate. These integrative clinical experiences prepare students for transition to practice and typically occur toward the end of the program.
The selection of experiences should be consistent with the desired course and curriculum outcomes, which may be multiple and specific to the nursing program. For example, the expected outcomes for students in an undergraduate degree nursing program are different than those for students in a graduate degree program. Therefore the learning experiences and clinical environment that are selected and the practice opportunities that are offered to students should be congruent with the program outcomes.
Interprofessional Clinical Education
Learning to collaborate with the many health care groups involved in patient care can be a daunting task. Through these experiences, nursing students can learn to work collaboratively with a variety of health disciplines. Therefore students should be provided with opportunities to work as members of interprofessional teams and in practice environments where practice models are used for joint planning, implementation, and evaluation of outcomes of care. The goal of interprofessional education is to foster development of teamwork competencies while enhancing contribution to each profession.
Interprofessional simulations may assist students in health care disciplines such as nursing, medicine, pharmacy, and respiratory therapy to learn about the clinical management of a variety of patients. Several recent studies demonstrate interprofessional simulations may improve patient care through shared learning, development of collaborative team functioning, and shared knowledge creation leading to trust and thoughtful decision making (Bandali, Craig, & Ziv, 2012; Reese, Jeffries, & Engum, 2010; Smithburger, Kane-Gill, Kloet, Lohr, & Seybert, 2013; Strouse, 2010).
Nursing faculty are increasingly participating in teams and designing interprofessional clinical courses and learning experiences. Successful course development and implementation depend on faculty’s commitment to the goal of interprofessional practice and a wide range of additional factors. For example, educators must demonstrate professional respect and role clarity. Educators must also have the ability to secure clinical facilities and develop schedules for clinical experiences that are compatible with the concurrent coursework and curriculum progression in each discipline. Other factors include identification of content and experiences with similarities, differences, and overlaps, as well as clarification of autonomy and role interdependency. Success depends on the ability to identify philosophical similarities and differences in clinical practice and to establish clear communication through avenues such as frequent interdisciplinary clinical conferences.
An expected outcome of interprofessional education is increased future collaboration among professionals (Interprofessional Education Collaborative Expert Panel, 2011). The assumption is that students who are taught together will learn to collaborate more effectively when they later assume professional roles in an integrated health care system. Rewards and benefits of interprofessional practice and education include clearer understanding of roles and better employment opportunities for graduates. The long-term outcome is improved access to care, quality care, and increased patient satisfaction and safety. (See also Chapter 11.)
Students are required to demonstrate multiple behaviors in cognitive, psychomotor, and affective domains. Consequently, clinical faculty must evaluate students in each of these areas. The evaluation must be both ongoing (formative evaluation) to assist students in learning and terminal (summative evaluation) to determine learning outcomes. Constructive and timely feedback, which promotes achievement and growth, is an essential element of evaluation. For a discussion of clinical performance evaluation, refer to Chapter 25.
Scheduling Clinical Practicum Assignments
Although faculty schedule clinical practicum experiences to promote learning, there is ongoing dialogue about the best way to schedule experiences, with emphasis placed on the length of the experiences (hours per day, number of days per week, number of weeks per semester), the timing of the experiences in relation to didactic course assignments, and student needs. Faculty should consider course goals related to both theory and clinical courses and integration of theory content with clinical experiences when making scheduling decisions.
When the learning goal is to integrate students into a clinical setting or when the students are working with a preceptor, students may work the same shift as the nurse with whom they are paired. Many acute care hospitals have a 8-hour shift option, whereas others have only 12-hour shifts. Giving students the opportunity to work the 12-hour shift affords the full scope of practice in any given nurse’s day. Students are able to quickly see and experience the role of the nurse. In one small study of senior nursing students in a second degree program working a 12-hour shift, Rossen and Fegan (2009) found that benefits included that students felt accepted by staff, had better socialization, and experienced a realistic work environment; disadvantages included decreased teaching time from the faculty. Although a shorter clinical day allows for skill acquisition, there is little time for the development of extensive critical thinking, clinical reasoning, and evaluation of care. It is equally important that students be exposed to the unit’s structure, operations, and culture.
Although results of research about outcomes and student satisfaction with timing and scheduling of clinical experiences offer some guidance, faculty also must consider additional variables such as availability of patients, clinical facilities, course schedules, and student needs. Scheduling is frequently influenced by the desire to have concurrent classroom and clinical experiences so that knowledge can be transferred and applied immediately. Clinical scheduling can be further complicated by the need to coordinate schedules of students from more than one school of nursing. Thus, ideal scheduling may not be a reality.
Effective Clinical Teaching
Clinical teaching must use multiple instructional techniques and teaching tactics to develop and adapt to the environment in which students have opportunities. The clinical instructor should implement activities aimed to foster mutual respect and support for students with each other while they are achieving identified learning outcomes. Faculty who teach in practicum environments are the crucial links to successful experiences for students.
Research about clinical teaching over time consistently indicates that effective clinical teachers are clinically competent, communicate clear expectations, are approachable, and can coach students through difficult patient situations (Dahlke et al., 2012). Additionally, students indicate effective clinical teachers have knowledge of the clinical environment and curriculum, make clinical learning enjoyable through supportive actions, express empathy, and communicate passion for the profession). Making clinical learning enjoyable involves helping students connect theory to practice and applying clinical reasoning while using a patient-centered approach to addressing problems (Dahlke et al., 2012).
Being knowledgeable and being able to share practice wisdom with students in clinical settings is essential. Such knowledge includes an understanding of the theories and concepts related to the practice of nursing. Equally important is an ability to convey the knowledge in an understandable manner. Karuhije (1997) directs attention to three discrete teaching domains that will facilitate acquisition of the teaching skills needed to foster success in clinical settings: instructional, interpersonal, and evaluative. Instructional refers to approaches or strategies used to facilitate a transfer of knowledge from didactic to practicum. Strategies may include questioning and peer or patient teaching. Faculty should be cognizant that the type of questions can cover a range during exchanges with students. Faculty should also be mindful of the manner in which questions are constructed to facilitate positive effects on learning. Questions that ask students to analyze and synthesize information, to make clinical judgments, to evaluate outcomes of care, or to propose alternative courses of action result in more learning than simple recall. In clinical practice, factors such as the nature of the situation and available time are likely to influence the types of questions raised.
Effective clinical teaching requires educators to coach students as they learn clinical reasoning and judgment. Clinical reasoning is a “complex process that uses cognition, metacognition, and discipline-specific knowledge to gather and analyze patient information, evaluate its significance, and weigh alternative actions” (Simmons, 2010, p. 1151). Clinical judgment is the outcome of the clinical reasoning process and is defined as “an interpretation or conclusion about a patient’s needs, concerns or health problems and/or the decision to take action (or not), and to use or modify standard approaches, or to improvise new ones as deemed appropriate by the patient’s response” (Tanner, 2006, p. 204). Clinical reasoning occurs when an individual has the ability to reason about the details of a particular clinical situation and identify what is salient (Benner et al., 2010; Tanner, 2006). Effective and efficient clinical reasoning is derived from knowing the patient, grasping baseline data, and understanding the case (Gillespie & Patterson, 2009). Clinical reasoning requires knowledge, skills, and abilities grounded in reflection. Clinical reasoning is supported by an individual’s capacity for self-regulation and leads to the development of expertise (Kuiper, Pesut, & Kautz, 2009).
Beginning students struggle with the ability to engage in clinical reasoning required to make sound judgments. The novice student does not have the ability to identify the subtle or relevant cues seen in a patient whose health condition is changing and for whom complications are beginning to occur. Faculty can assist students in identifying these subtle and relevant cues and start to collaborate with other health care professionals to provide the interventions needed to anticipate potential problems and consider the options aimed toward eliminating or treating complications (Cappelletti, Engel, & Prentice, 2014). (See Box 17-1).
Clinical ReasoningSubtle Changes and ComplicationsRelevant “Cues”Anticipated Collaborative InterventionsAnticipated OutcomesPulmonary edema
• Breath sounds (crackles, wheezing)
• Semi- or high Fowler’s position
• Decreased shortness of breath
• Implement call orders related to low O2
• Increase FiO2 and PaO2
• FiO2 % decreased
• PaO2 decreased
• Using SBAR, contact physician to obtain orders
• Increased U/O
• Shortness of breath
• Anticipate the following:
• No accessory muscle use
• Diuretic: (e.g., Lasix)
• Clear breath sounds
• Chest X-ray
• Decrease IV fluids
• No arrhythmias associated with low K +
• Give K + if low
• Accessory muscle use
• Blood-tinged sputum
• Hypertension or hypotension
Coaching and Giving Feedback
Coaching students to help them develop clinical competency requires giving students feedback. Feedback, an essential element in teaching and learning, is described as information communicated to students as a result of an assessment of an action by students (Wells & McLaughlin, 2014). Feedback, when properly delivered, has a high potential for learning and achievement. In clinical practice where assessments need to be made about the extent to which clinical competencies are met, clinical faculty have a variety of opportunities to offer feedback in response to performance behaviors relating to psychomotor as well as cognitive and affective actions. Regardless of the action, key considerations should be practiced. These considerations are specificity, timing, consistency, continuity, and approach. Approach is important because of its capacity to alleviate anxiety and enhance engagement.
Because of the variations in needs of students, each clinical experience provides opportunities for feedback. It is imperative that feedback not be given only at documented, scheduled times for formative and summative evaluations. Faculty should be cognizant of those actions that require immediate interaction and those for which feedback can be delayed until a short time later, but not too much later. Methods must be identified to maintain data for timely sharing both strengths and challenges with students, for example. Faculty should create an efficient system for making brief written or electronic anecdotal or mental notes. The delivery of feedback can take multiple forms and depends on the situation. Face-to-face, time-sensitive, brief conferences (e.g., a few minutes) or electronic conversations or dialogue are examples.
Regardless of the method of delivery, guiding principles must be applied and the learning intent of feedback should be provided. Knowing how to give feedback regarding clinical performance and written clinical assignments is an important element of teaching. One method is to point out positive aspects of performance as well as areas that require improvement. Some situations may provide an opportune time to role-model. For example, if a student fails to integrate communication while performing a procedure, faculty can fill in the missing words. Such action may (or may not) alert the student to an “aha” learning moment: “I failed to communicate. . . .” The faculty interjecting could have a lasting outcome. See Chapter 25 for information about assessing clinical learning and the delivery of feedback.
Debriefing and guided reflections are forms of feedback often used immediately following a clinical experience, nursing rounds, simulation, or presentation to determine the extent to which expectations were met and identify any areas of concern (Overstreet, 2010). In the process of making determinations, the discussion often evolves into identifying areas needing improvement. Although debriefing sessions generally take place in group settings (e.g., in clinical conferences), it is not uncommon for sessions to occur on a one-on-one basis. Faculty may take the lead by posing specific questions and listening to responses to guide further discussion. Students assume an active role in debriefing sessions and can take the lead in initiating the process (Dreifuerst, 2012).
Effective clinical teachers are expected to have expertise in the “art” of teaching. Equally important are teacher behaviors that facilitate learning and support students in their acquisition of nursing skills. Empirical evidence correlates specific teaching methods with enhanced student learning. A recent study suggests effective clinical teaching involves the ability to optimize the environment to provide meaningful learning experiences focused on predetermined objectives (Gubrud-Howe & Schoessler, 2009). Facilitation of cooperative learning, active engagement, and the use of a variety of methods for learning has been reported to be highly effective (Dahlke et al., 2012). Common examples of cooperative strategies are peer teaching and pairing students for student-to-student instructions. Other effective 291behaviors include sharing anecdotal notes, using objective language when giving feedback, probing to help students self-correct misunderstandings, and communicating expectations clearly.
Effective Clinical Teaching Behaviors and Attitudes
Teaching behaviors that facilitate students’ development in higher-order thinking skills include prompts to help students recognize the salient cues in a situation, prioritization, retrieval, and application of theoretical and factual knowledge from coursework. Most importantly, effective clinical instruction focuses on helping students to think contextually with intent to understand the unique characteristics of the patient’s situation at hand (Benner et al., 2010). Included among motivational strategies are discussing course goals and relating them to the practicum arena, exhibiting enthusiasm about the profession, discerning student expectations, establishing reward systems, and trying new and different teaching strategies. Strategies that facilitate thinking modalities also include logic models (Ellerman, Kataoka-Yahiro, & Wong, 2006), case studies, and concept mapping. These strategies can be used in the classroom as a way to prepare students for clinical practice and to bridge the gap between didactic courses and clinical learning experiences.
Teacher behaviors relating to interpersonal skills are reported to affect student outcomes. Behaviors such as showing respect for students and treating students with respect (Dahlke et al., 2012), correcting mistakes without belittling), and being supportive and understanding are helpful.
Nursing students experience stress and anxiety in clinical learning situations (Elliott, 2002; Lo, 2002; Timmins & Kaliszer, 2002). Negative relationships with faculty can contribute to anxiety (O’Mara et al., 2014). The effective clinical teacher recognizes students’ need for supportive and collegial relationships and develops an interpersonal style that promotes a collegial learning environment; O’Mara et al., 2014). Positive relationships are nurturing and can enhance learning. Caring behaviors and a caring environment are also essential (O’Mara et al., 2014).
The literature points to the importance of building relationships between students and teachers. It is believed that the quality of their interaction affects learning outcomes (Tanner, 2005). Concepts that facilitate the building of relationships may include the following: connections, caring, compassion, mutual knowing, trusting and respecting, availability, knowledge, confidence, and communicating (Gillespie, 2002). By knowing the students’ strengths, challenges and individual goals, faculty are prevented from making assumptions and reacting to students’ misunderstandings or poor performance. Making assumptions regarding student intent or motivation may be perceived by students as being disrespectful. Making connections to identity early in the relationship assists faculty in determining the elements needed to meet students’ learning needs (Dahlke et al., 2012; O’Mara et al., 2014).
Teacher confidence is another factor that enhances learning; teachers who lack confidence actually create distance between themselves and the students they teach). This hinders the sense of knowing and the possible connections that may have formed. A part of teacher confidence is a foundation of knowledge. When clinical teachers use their expertise to support learning, the teacher–student relationship is strengthened.
Cook (2005) engaged in a study to explore perceptions of teacher behaviors that invite trust and create student anxiety. The findings indicate that teachers need to be aware of how their behaviors can be negatively perceived by students, thus influencing the anxiety that occurs during the clinical experience and ultimately affecting learning. Senior clinical faculty should serve as role models and mentor junior clinical faculty to create a legacy of effective clinical teaching. Additional characteristics of effective teachers are listed in Box 17-2.
Characteristics of Effective Clinical Teachers
1. Create an environment that is conducive to learning that requires:
• Knowledge of the practice area
• Clinical competence
• Knowledge of how to teach
• A desire to teach
2. Be supportive of learners. Such support requires:
• Knowledge of the learners
• Knowledge of the practice area
• Mutual respect
3. Possess teaching skills that maximize student learning. This requires an ability to:
• Diagnose student needs
• Learn about students as individuals, including their needs, personalities, and capabilities
4. Foster independence and accountability so that students learn how to learn.
5. Encourage exploration and questions without penalty.
6. Accept differences among students.
7. Relate how clinical experiences facilitate the development of clinical competence.
8. Possess effective communication and question skills.
9. Serve as a role model.
10. Enjoy nursing and teaching.
11. Be friendly, approachable, understanding, enthusiastic about teaching, and confident with teaching.
12. Be knowledgeable about the subject matter and be able to convey that knowledge to students in their practice areas.
13. Exhibit fairness in evaluation.
14. Provide frequent feedback.
Preparing Faculty for Clinical Teaching
The preparation and development of faculty for clinical teaching are not as widely discussed and documented as the preparation of students for clinical learning. Studies indicate that the exposure of faculty to evidence-based teaching strategies and learning theory is minimal (Dahlke et al., 2012; McNelis et al., 2014). Krautscheid, Kaakinen, and Warner (2008) directed efforts to facilitate a reversal in this trend. A clinical faculty development 292program, developed to help faculty practice teaching by analogy and reflect on clinical teaching, was implemented. With this program, clinical teaching simulations were used to allow faculty to practice, teach, and receive immediate feedback. Scenarios were used to facilitate the process. As a result of the clinical teaching simulations, faculty reported being more reflective as teachers and practitioners and identified the importance of facilitating a safe learning environment in the clinical practice setting.
Expert clinicians often have a desire to teach in the practicum area. Providing the faculty development needs of expert clinicians can be challenging. It can be very difficult to equip clinicians with teaching skills required to be an effective clinical teacher for those faculty who also maintain full-time clinical practices. Some have been preceptors and to fully attain the skills needed to make the transition to a new role as clinical teachers, further instruction, coaching, and guidance is required. These individuals should be encouraged and provided with information about where and how they can engage in activities that will facilitate their acquisition of the knowledge and skills required for the clinical teaching role. Some schools have developed modules for that purpose.
One method for meeting the challenge of educating clinical teachers is to use an online course to orient clinicians who are making the transition from the role of expert clinician to that of clinical teacher (Reid, Hinderer, Jarosinski, Mister, & Seldomridge, 2013). Essential topics include teaching–learning theory, critical thinking, how to deal with challenging students, and making patient assignments. Because being an excellent clinical nurse does not mean that the nurse will be an excellent teacher, Cangelosi, Crocker, and Sorrell (2009) developed a Clinical Nurse Educator Academy to prepare clinicians for clinical teaching. After analyzing reflective papers at the end of the academy, the authors found that the nurses were enthusiastic about the educator role, but that the frustration from lack of mentoring indicates a need for ongoing development of the educator role.
In summary, effective clinical teachers are knowledgeable and know how to convey concepts to students in effective ways, are clinically competent, coach students to develop clinical reasoning and judgment, exhibit interpersonal skills that positively influence students’ learning, and establish collegial relationships that often last well beyond a specific course or program. Clinical faculty also need to be oriented to and developed for the role. Research is likely to continue in this area.
Preparing Students for Patient Care
Teaching for patient care should involve orderly and logical actions taken to accomplish particular educational goals. The actual selection and use of a particular strategy should be based on expected outcomes, principles of learning, and learner needs. This section focuses on several strategies commonly used in clinical teaching: patient care assignments, clinical conferences, nursing rounds, and written assignments.
Students come to the health care environment not really understanding the culture of confidentiality. It is imperative that students know and understand the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security regulations. It is the role of faculty to instruct students on the need to implement the HIPAA rules and regulations in all patient encounters. They are designed to protect the patient’s right to privacy. Students should be informed of what they can and cannot do in relation to confidentiality, and these instructions must be enforced.
Patient Care Assignments
Patient care provides students with opportunities to integrate, synthesize, and use previously learned knowledge and skills. Some nursing courses require students to prepare in advance for their clinical experience. Advance preparation commences with making clinical assignments, which may be the responsibility of the clinical teacher, the teacher and student together (especially useful for beginning students), the student alone, the student with guidance from the teacher, or the nursing and health care staff or preceptors. Allowing students some input into selecting clinical assignments encourages them to be self-directed as well as to choose experience on the basis of their personal learning needs. Refer to Box 17-3 for other suggestions for making assignments.
Tips for Making Assignments
New faculty often are at a loss in knowing where to begin. The following tips should assist new faculty to enhance their comfort level in implementing this task.
• Come to the unit with knowledge of specific student needs.
• Have an assignment sheet with a list of the students for the given day.
• Get input from those in charge and from the staff nurses.
• Talk to the nurse in charge and ask for brief suggestions about the patients on the unit. This simple act of communication is one way to build a trusting, supportive relationship with the staff on the unit, as they can be very helpful in guiding what patients will make for a good assignment.
• Make rounds and talk to all of the patients and family you plan to care for on the following day. Just a few minutes chatting can assist you in deciding whether a patient will be appropriate for a student nurse.
• Obtain patient and family permission, as this may prevent early morning assignment changes because a patient refuses to have a student.
• Consider the specialty on your particular unit. Knowing the patient population will help determine when to make assignments. For example, if it is a surgical unit, you may want to make assignments later in the afternoon because patients may be admitted late to the unit following surgery. If you make an assignment too early, you may risk the problem of a patient being reassigned to a different unit or discharged.
• Be sure that students know who the charge nurse is in case the assignments need revision when faculty are not available. Establishing a protocol for this will lessen frustration among the staff.
• Always have a backup plan. Add a couple of extra patients to the assignment sheet in case something changes when faculty are not available.
The selection of clinical assignments by students in collaboration with others has several benefits. It provides opportunities for students to select experiences that are based on personal learning needs, to experience a degree of control over their education, and to interact with practicing professionals during the process of selecting experiences. The extent to which students are permitted to self-select experiences depends on the goals or expected outcomes of the program, the philosophy of the specific clinical teacher, and the availability of resources in the clinical environment to assist students (i.e., to answer questions and provide guidance in patient selection).
Involvement of the clinical faculty is important when students select their experiences. For example, faculty serve as resource advisers and sources of emotional support, communicate goals and intended outcomes, assist students in assessing the congruency between personal learning needs and course objectives, facilitate planning the experiences, collaborate with students as they strive to meet goals, and evaluate accomplishments. Making clinical assignments can be a challenge for clinical faculty. Novice faculty are often at a loss in terms of knowing where to begin. This is where mentoring by senior-level or expert faculty is helpful.
Strategies for Implementing Clinical Assignments
Clinical assignments are an integral part of nursing practicum experiences. Several strategies for making clinical assignments have been adopted for 294clinical teaching. The strategy used in clinical instruction is often determined by factors such as the skill level of the student, the patient acuity level, the number of assigned students, and the availability of patients and resources, including the availability of technology. Traditional and alternative strategies, such as dual assignments, multiple assignments, and clinical conferencing, are discussed.
The traditional strategy is one in which nursing students are taught in a clinical setting with a varying faculty-to-student ratio. Ratios should be determined with an aim for facilitating optimum learning, knowledge of regulatory and agency requirements, and consideration of the workflow of the unit or agency. Most importantly, consideration of patient safety and quality care is essential (Ironside & McNelis, 2010; McNelis et al., 2014). The rationale for these ratios relates to the effect of increased numbers of students on patient safety (Ironside & McNelis, 2010). From a student’s perspective, this strategy involves the assignment of one student to one or two patients. The students assume responsibility for the nursing interventions needed in the care of the patient and may work alone in planning, implementing, and evaluating nursing activities.
Alternatives to the traditional method of clinical assignment are dual and multiple assignments. The dual assignment strategy (Fugate & Rebeschi, 1991) involves assigning two students to one patient. This alternative is useful when the level or complexity of care is beyond the capabilities of one student. Because students must work closely to implement care, collaboration and communication between the students are requisites for effective use of this strategy. Benefits of this strategy include improved time management, opportunities for collaboration and peer support, and fewer numbers of patients for which the faculty is responsible. When dual assignments are made, faculty have the responsibility of ensuring that each student understands his or her specific responsibility. For 2-day clinical rotations, roles may be reversed on the second day of care). Such reversal makes it possible for both students to direct care to the patient.
The strategy of multiple assignments is useful for beginning students and in situations where a limited number of patients are available. This strategy involves the assignment of three students per patient. Three roles are assumed: the doer who provides the care; the information gatherer or researcher who is responsible for obtaining information needed for the safe care of the patient; and the observer who observes the student, the researcher, the student–patient interactions, the responses of the patient to his or her care, and the family members. The observer also makes suggestions for improving care. As with dual assignments, the roles for each student must be clearly defined. Adequate time must be made available for collaboration and discussion among students and faculty.
The multiple assignment approach must meet learning objectives. Glanville (1971) conducted a study to determine the effectiveness of this method as an approach to clinical teaching. Results revealed similarity in the extent to which objectives were met and in the levels of achievement for students assigned to the multiple assignment approach and those assigned to the traditional method. VanDenBerg (1976) randomly assigned 22 first-year associate degree students to two groups, one of which used traditional assignments and one of which used multiple assignments. Results showed that students assigned to the multiple assignment group demonstrated a significant increase in nursing knowledge compared with those assigned to the traditional group.
In light of the increasing complexity of learning environments and the instability of the patient census, consistent clinical assignments and multiple placement assignments were compared to determine learning outcomes (Adams, 2002). Here, consistent means that students were assigned to a unit for a specific time frame or used more than one unit during the period. Quantitative measures revealed no difference in the two methods of clinical rotation. However, the perceptions of the benefit of consistent clinical assignments were positive.
In summary, faculty, staff, and students play a significant role in determining assignments. Assignments are made according to a number of factors, including course objectives, learner needs, skill level, complexity of the clinical environment, and patients’ acuity. The assignments may be implemented as solo or multistudent experiences. Each has been considered beneficial in enhancing learning.
Clinical conferences are group learning experiences that are an integral part of the clinical experience. The use of clinical conferences in nursing is common. Conferences can provide meaningful 295learning experiences and excellent opportunities for students to bridge the gap between theory and practice. Through conferences students can develop critical thinking and clinical decision-making skills (Wink, 1995) and acquire confidence in their ability to express themselves with clarity and logic.
Successful clinical conferences are planned. Plans for conferences should take into consideration the curriculum and the learner. An identification of the purpose, topic, process, strategies, and methods of evaluation are essential if the teacher is to be instrumental in bridging the gap between theory and clinical practice.
Types of Conferences
The conferences can include traditional preclinical, midclinical, and postclinical conferencing. As a result of advancing technology, conferences may take place through electronic media and online. As such, the rules and regulations related to HIPAA and the Health Information Technology for Economic and Clinical Health Act apply to clinical groups that use clinical conferencing by electronic media. Student groups must be aware of maintaining patient confidentiality as the group presents patient data by electronic means. Using this form of conferencing is a means of using technology while supporting the needs of students. Some may be doing clinical assignments at different sites and electronic conferencing brings students together where debriefing can occur without having to travel to a central location.
Preclinical, midclinical, and postclinical conferences by nature are small-group discussion periods that immediately precede, occur during, or follow a clinical experience. Each provides opportunities for discussion. In preclinical conferences, students share information about upcoming experiences, ask questions, express concerns, and seek clarification about plans for care. Preclinical conferences also provide opportunities for faculty to correct student misconceptions, identify problem areas, assess student thinking, and identify student readiness to implement care.
Midclinical conferencing, in contrast to preclinical and postclinical conferencing, is another form of gathering students together to provide some form of midclinical debriefing. It has been found that, while doing a 12-hour clinical day, this gives students an opportunity to gather to share pertinent patient information and plan for further interventions, which may include patient teaching and discharge planning. This midclinical conference time also may help students collectively evaluate the efficacy of prior patient interventions. This exchange of data, in the form of a midconference, is a method of imparting knowledge and sharing common data with the intent of positively affecting patient care.
Postclinical conferences provide a forum in which students and faculty can discuss the clinical experiences, share information, analyze clinical situations, clarify relationships, identify problems, ventilate feelings, and develop support systems. In postclinical conferences there is interaction between the teacher and the students, which offers both a medium for learning and an exchange resulting in meaningful experiences.
Online conferencing, occurring before or after clinical experiences, can assist students to come together in a virtual environment to exchange ideas, solve problems, discuss alternatives, and acquire information about issues of clinical care that occurred before or during the clinical experience (Gaberson, Oermann, & Shellenberger, 2015). See Chapter 21 for further discussion of teaching in online learning communities.
Student and Faculty Roles during Conferences
Both students and faculty have specific roles in conferences. Student should be made aware of their role as active participants. As such, they should defend choices of care, clarify points of view, explore alternatives, and practice decision making. A student may also assume the role of group leader. Faculty serve as conference facilitators by supporting, encouraging, and sharing information; posing questions and asking for alternative hypotheses; giving feedback; helping students identify patterns; and guiding the debriefing process. As conferences are facilitated, efforts should be made to ask higher-level questions that assist students in applying knowledge to clinical situations (Gaberson et al., 2015). Conferences also provide opportunities for students to apply group processes and develop team-building skills.
Evaluating the Conferences
Conferences should be evaluated in light of their effectiveness and goal accomplishment. The teacher should obtain and provide feedback regarding the extent to which goals were accomplished, the effectiveness of the teaching methods or strategies, and the 296degree of learning achieved. The data from the evaluation can be used for planning future conferences.
In summary, traditional and electronic conferences play a significant role in facilitating students’ learning. Conferences afford opportunities for enhancing critical thinking, clinical reasoning, and decision-making skills; for creating new meaning for care issues; and for enhancing group process and team-building skills. Successful conferences are planned. Inherent in planning are identifying the purpose, selecting topics, selecting teaching methods, and conducting and evaluating these methods.
Complementary Clinical Experiences
Nursing Grand Rounds
The practice of nursing grand rounds is a teaching strategy that uses the patients’ bedside for direct, purposeful experiences. These experiences may involve demonstration, interview, or discussion of patient problems and nursing care. Rounds also afford an excellent opportunity for the exchange of ideas about patient care situations, which may involve clinical faculty, students, and staff.
The use of rounds as a teaching strategy requires planning. Planning includes obtaining permission from the patient and providing information about the nature of the rounds and the role the patient will play. After the session, patient participation should be acknowledged and some form of debriefing should occur, including planning for subsequent rounds.
Concept-Based Learning Activities
Concept-based learning activities are a type of experience used recently in clinical education (Gubrud-Howe & Schoessler, 2009; Nielsen, 2009; Nielsen, Noone, Voss, & Matthews, 2013). This learning activity is designed to develop deep learning and pattern recognition of a particular health problem or medical diagnosis. Concepts are identified for students to study in the context of the patient care environment. Fluid and electrolytes is an example of a concept students may explore. Each student completes an in-depth assessment of a patient with a fluid and electrolyte problem. The pathophysiology, treatment, pharmacology, and patient response to care is explored. The faculty facilitates comprehensive discussion of each case and directs discussion so students begin to see the similarities and differences between each patient in an effort to begin to identify salient findings related to each case. The faculty help students identify unexpected findings in the patients’ situation related to the concept being studied and help students recognize current or potential complications that need to be addressed. Students are not responsible for care but need to address any safety issues that emerge as they are assessing their assigned patient. This activity allows the student to focus on critical thinking about the concept being studied without the distraction of attending to tasks associated with general patient care (Nielsen et al., 2013). Communicating the focus of this assignment and learning activity with staff is essential to avoid misunderstanding of the student’s role on the unit (Gubrud-Howe & Schoessler, 2009).
Written assignments generally complement clinical experiences and are considered to be useful in that they facilitate development of critical thinking and clinical reasoning and they promote an understanding of content. Such assignments may include short papers, clinical reasoning papers, nursing care plans, clinical logs, journals, and concept maps. Findings from research on the use of clinical logs indicate that their use provides opportunities for students to reflect on clinical experiences, communicate with the teacher, identify mistakes and negative experiences, and learn from these experiences. See Box 17-4 for possible journaling questions.
Sample of Journaling Questions
• How did you feel about your clinical day?
• What was the best part of your clinical day?
• What did you feel most confident about?
• If you could do your clinical day over, what would you do differently?
• What were you most concerned about as related to your patient’s care?
• What did you learn today that can apply to future patients with similar problems?
• What do you need to learn more about?
• Describe interactions with other professions. What went well? Describe how the interaction was or was not patient centered.
• Describe any patient quality or safety issues you had to address or manage. What goals do you have for your next clinical day?
Point-of-Care Technology and Mobile Health
Nurses are increasingly using handheld devices, electronic health records, and other point-of-care technologies in the clinical setting, and faculty must provide opportunities for students to become familiar with their use. Simulated electronic health records can be embedded in clinical simulations as preparation for their use in the clinical agency or as a substitute for learning when agency policy precludes students’ use of them in the agency. Smart phones equipped with reference software enable access to clinical information; care plans; and nursing, procedure, and evidence-based practice guidelines; and can provide access to skills videos and patient teaching materials (Zurmehly, 2010). Increasingly, nurses are using software applications (“apps”) on a smartphone to diagnose, monitor, and teach patients in community-based settings; students must have experience using these point-of-care and mobile health technologies as well. See Chapter 19 for information about policies for using technology in clinical settings.
Models for Clinical Education
Several models for clinical education are used to educate nursing students. These models, alternatives to the traditional model, include preceptorship, associate model, paired model, academia–service partnerships, and adjunct faculty joint appointments. These models have evolved to increase capacity for clinical placements, facilitate development of competency for today’s practice, manage faculty shortages, prepare graduates to be competent for practice, and foster closer ties with clinical agencies (Delunas & Rooda, 2009; Murray, Crain, Meyer, McDonough, & Schweiss, 2010; Neiderhauser, Macintyre, Garner, Teel, & Murray, 2010; Niederhauser, Schoessler, Gubrud-Howe, Magnussen, & Codier, 2012; Nielsen et al., 2013). Given the diversity of health care settings, faculty shortage, and the need for reduced faculty-to-student ratios, new models serve to enhance effective student learning, facilitate development of clinical skills, and promote role development.
Preceptorship is a teaching model in which the student is assigned to a nurse who serves as a preceptor. Preceptors are experienced nurses who facilitate and evaluate student learning in the clinical area during a specified time. Their role is intentionally implemented in conjunction with other responsibilities related to patient care in the clinical environment. The preceptor model is based on the assumption that a consistent one-on-one relationship provides opportunities for socialization into practice and bridges the gap between theory and practice. The preceptor model may be used at several levels. However, it is considered to be particularly useful for senior-level students and graduate students in advanced practice roles. Use at these levels provides opportunities for students to synthesize theoretical knowledge and apply information, including evidence-based research, in the practice environment. This method is also an excellent way for students to practice collaboration.
Theoretically, the preceptor provides one-on-one teaching, guidance, and support, and serves as a role model. In one model (Billings, Jeffries, Rowles, Stone, & Urden, 2002), the preceptor, faculty, and student form a triad to facilitate the student’s acquisition of clinical competencies. The preceptor may be assigned to a student on the basis of shared learning needs. The preceptor and student meet before the first clinical experience to discuss learning styles and goals for competency attainment and the desired outcome of the clinical experience. Although faculty have ultimate responsibility for the course and students’ learning outcomes, the student and preceptor are empowered to conduct formative and summative evaluations of the student’s clinical performance and learning outcomes. In the Integrative Clinical Preceptor Model (Mallette, Laury, Engleke, & Andrews, 2005; Mamhidir, Kristofferzon, Hellström-Hyson, Persson, & Mårtensson, 2014), the student assumes a proactive role, not only as a student, but also as a member of the health care team. In this model, the preceptor assumes responsibilities as a clinical teacher, mentor, and role model, and faculty serve as a role model and facilitator for the preceptor and the student as well as a consultant.
Preceptors are expected to be clinical experts, to be willing to teach, and to be able to teach effectively (McClure & Black, 2013). Benefits that have been derived from preceptorships include enhanced ability to apply theory to practice, improvement in psychomotor skills, increased self-confidence, and improved socialization. Attributes of an effective preceptor are listed in Box 17-5.
Attributes of an Effective Preceptor
1. Knowledge of the patient care area
2. Effective communication skills (verbal and nonverbal)
3. Experience in a particular clinical area
4. Ability to relate to health care personnel and client
6. Effective decision-making skills
7. Genuine caring behaviors
8. Leadership skills
9. Interest in professional development
Used with permission from Lewis, K. E. (1986). What it takes to be a preceptor. The Canadian Nurse/L’infirmière Canadienne, 82(11), 18–19.
In a preceptorship, the role of the nursing faculty transitions from direct instruction to an emphasis on facilitation and evaluation. Preceptors and faculty must work in a close relationship). Faculty provide the link between practice and education. In providing this link, faculty monitor how well the students complete assignments and accomplish outcomes. Evaluation is a collaborative responsibility of faculty, students, and preceptors but most nurse practice acts require the faculty to assume accountability for evaluating the student’s attainment of learning outcomes.
The use of preceptors requires that planning be done to ensure an understanding of their role. Ideally this is facilitated through strategically planned orientation and follow-up sessions; some schools of nursing offer workshops or courses to orient preceptors to their role (McClure & Black, 2013; Smedley & Penney, 2009). These sessions provide a forum for sharing information related to the philosophical perspectives of preceptorship, expected outcomes, teaching strategies, and methods of evaluation. Because roles change for faculty, students, and preceptors, all require orientation to new roles (McClure & Black, 2013; Mallette et al., 2005).
The value of the preceptor model is generally related to providing students a sense of independence for patient care and the ability to develop a professional identity. Preceptors and clinical agencies also value the preceptor model because preceptors develop additional skill sets related to teaching and the clinical agency that stands to benefit from hiring a well-prepared graduate.
Clinical Teaching Associate
The clinical teaching associate (CTA) model involves a staff nurse who collaborates with a designated faculty member and instructs a specified number of students in the clinical area (Baird, Bopp, Schofer, Langenberg, & Matheis-Kraft, 1994; DeVoogd & Saldbenblatt, 1989). Teaching responsibilities are assumed by the CTA, who also serves as a resource person and role model. A faculty member serves as lead teacher and is responsible for supervision and evaluation of clinical learning experiences, including assignment of grades and collaboration with the CTA about assignments and experiences.
Results from a survey of nurse managers, CTAs, faculty, and students conducted to determine the effectiveness of this model were positive (Baird et al., 1994). Positive comments were presented in terms of student learning. Patient satisfaction with care was reported to be greater than with the traditional model. Nurses in the CTA role reported an increase in student confidence. Faculty reported that students were more relaxed and more self-confident. The effectiveness of the model was reported by students as allowing them to assume increased responsibility in comparison with the traditional model.
The paired model is designed to pair a student and a staff nurse for a practicum experience. It is an alternative to the one-patient, one-student model and is a variation of the preceptor model. This model is often used in combination with the Dedicated Education Model and in community-based setting such as an ambulatory care center or clinic. During the course, each student has a specified number of days in a paired relationship. The remaining time is spent acquiring experiences by using the traditional model. The staff nurse plans the learning experience; the faculty member oversees the experiences while creating a learning environment for students. However, most of the faculty member’s time is spent in the traditional role with other students who have not been paired. To enhance the effectiveness of the paired model, it is essential that the staffing pattern be evaluated before making assignments.
The clinical teaching partnership is a collaborative model shared by service and academia settings to enhance mutual goals of developing nurses 299competent for practice and creating safe practice environments. Partnerships are also formed to create new models of clinical instruction and increase student and faculty capacity in nursing programs (Delunas & Rooda, 2009; Nielsen et al., 2013). Although these partnerships take different forms, they are established collaboratively and result in redesigned clinical education experiences for students and faculty as well as for the nurses at the clinical agency. Academic and service partnerships are a promising framework to address the nursing faculty shortage.
In one early partnership model, the service institution shared the resources of nurses, a clinical nurse specialist (CNS), and an academic faculty member (Shah & Pennypacker, 1992). The CNS serves as an adjunct faculty member who provides patient assignments. The academic faculty member schedules the experiences. Jointly they collaborate in evaluating assignments facilitating learning experiences and assessing students’ performance. Communication is reciprocal and essential to the success of this model. The faculty member shares information about problems that may influence students’ performance. The CNS keeps the faculty member abreast of current student performance. Both schedule conferences to discuss anecdotal records of students. Murray et al. (2010) report that students in their partnership model were better integrated into the clinical setting and increased levels of critical thinking and clinical decision making.
Adjunct faculty are health care professionals who are employed in the service setting and have a part-time academic appointment. Adjunct faculty may assume various roles, including those of preceptor, CTA, mentor, guest lecturer, and supervisor. These individuals may also collaborate on research projects. Faculty who are appointed in an adjunct capacity are registered professional nurses or professionals who are experts in areas such as clinical practice, research, leadership, management, legislation, and law.
Dedicated Education Units
Over the past decade, the dedicated education unit (DEU) model has been implemented at various universities across the country. Moscato, Miller, Logsdon, Weinberg, and Chorpenning (2007) indicate that the “DEU offers a concrete strategy to more closely connect nursing units and education programs” (p. 32). DEUs involve new partnerships among nurse executives, staff nurses, and faculty for transforming patient care units into environments designed to support learning experiences for students and staff nurses while continuing the critical work of providing quality care to acutely ill patients. Mulready-Shick, Flannagan, Banister, Mylott, and Curtin (2013) found that the DEU model facilitates stronger relationship building between nurses in academia and practice, and students report significantly more positive learning experience when compared with traditional clinical placement experiences. Universities are implementing this strategy in a variety of ways. One Midwest university uses the term practice education partnership (PEP) units. The PEP unit is a hospital-based unit designed to provide the student with a strong partnership between the practice and education settings. The PEP model differs from the Australian DEU model in that it works to incorporate the culture of the unit and its clinical specialty into the availability of preceptors, level of patient acuity, and other influences on the education of the student. One of the unique aspects of the PEP model is that there is continuity and consistency among preceptors, faculty, and students as they partner to learn and grow together. Preceptors are coached on preceptor competencies by attending a full-day workshop. It is at this time that the partnership between the nurse and the faculty begins. This partnership is developed over time and ultimately the student learns the role of the nurse and together the student and preceptor provide exceptional patient care.
The use of DEUs has increased significantly in the last decade (Moscato, Nishioka, & Coe, 2013). Research indicates the educational quality and competency development are significant for students receiving clinical instruction in DEUs (Dapremont & Lee, 2013; Mulready-Shick et al., 2013).
Recognizing that prelicensure programs may not be sufficient for preparing nurses for practice in complex health care settings, several studies and commissions (Benner et al., 2010; Institute of Medicine, 2010; Tanner, 2010) report on the need for postgraduate residencies and call for their increased use to improve transition to practice and development of leadership and population management skills. Accreditation and regulatory standards have been developed for this 300approach to residency. The American Association of Colleges of Nursing (AACN) developed a 12-month program designed to facilitate further development of competency and ease the transition into practice. The AACN piloted six programs in 2004 and there are now residency programs in more than 30 states (Barnett, Minnick, & Norman, 2014). The NCSBN developed a model that provides a framework for standardized transition to practice and regulatory guidelines are under consideration (Goode, Lynn, McElroy, Bednash, & Murray, 2013).
Several studies have been conducted to examine the outcomes of nurse residency programs (Goode et al., 2013). The findings suggest nurse residency programs increase overall confidence and competence particularly in the ability to organize, prioritize, communicate effectively, and provide leadership (Goode et al., 2013). Residency programs have a statistically positive influence on nurse retention rates (Goode et al., 2013). Further research is needed to determine the influence of postgraduate nurse residency programs on patient outcomes (Barnett et al., 2014).
In summary, several models for clinical education of student nurses exist. Alternative models, collaborative in nature, have evolved because of the increasing complexity of the health care environment. Among these models are preceptorships, the teaching associate model, the paired model, clinical teaching partnerships, and adjunct faculty. The nature of each model dictates the level of student that would benefit most. The paired and clinical associate models have been used for beginning students, whereas the preceptorship model is widely used for students in the upper level of their program and for graduate students. Empirical research on the effectiveness of these models has been sparse; there is a need for further evaluation of and research on these models in terms of their effectiveness on student learning and preparation for the workforce.
Clinical teaching involves student–teacher interaction in experiential clinical situations that take place in diverse and often interprofessional practice environments. These environments may include laboratory, acute care, transitional, and community sites, including homeless shelters, clinics, schools, camps, and social service agencies. Faculty must have in-depth knowledge of teaching behaviors that facilitate students’ learning and development, and have complete knowledge of the culture of the practice area as well as the health care provider. Effective clinical teachers are able to plan, facilitate, and evaluate experiences using instructive, interpersonal, and evaluative strategies. These strategies facilitate faculty’s acquisition of the knowledge and skills required to become nurses.
A variety of teaching methods can be used to enable students to achieve desired outcomes. Patient assignments, clinical conferences, nursing grand rounds, concept-based clinical activities, and written assignments are among these. The skill level of students, patient’s acuity level, number of students, and patient care resource availability will affect the method used. Among the models suggested for educating nursing students are the traditional approach and alternatives to this model, including preceptorships, CTAs, teaching partnerships, and adjunct faculty. Practicum experiences prepare students for working in a health care system that is evidence based and patient centered. Teaching in the practicum setting blends faculty’s clinical expertise with teaching skills to prepare nurses for current and future roles in an ever-changing health care system.
Reflecting on the evidence
1. Choose a set of clinical teaching strategies for a group of students. What do you need to consider about the student, the setting, and the patients in order to make this decision? What evidence for practice will you draw on to make your decision?
2. What is the role of Internet-based teaching and learning in clinical teaching? Can clinical practice be learned in a fully online course?
3. What is the state of science about clinical teaching? What research questions are being asked? What methods are being used? What variables are included in the studies?
4. What are the best practices that are evidenced-based?
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