CHAPTER 4 One instructor … would yell and belittle us in front of the other students. … I firmly believe that all people need to feel respected and valued. —Hannah I was in my first weeks of clinical as a nursing student. I was young and inexperienced in talking to patients, and very shy. I was assigned to give a bed bath to an elderly man and was very nervous about remembering all the steps I had learned in the skills lab. I concentrated intently on folding the washcloth the right way, making sure that the water in the washbasin was the right temperature, and keeping the patient covered with a bath blanket while doing the bath so that he would not feel cold. I thought the procedure went well and the patient thanked me warmly for my care. Later that day, my instructor called me into the conference room to talk. “I was watching outside the curtain this morning when you were bathing your patient,” she said. “Maybe you don’t realize it, but you hardly said a word to him the whole time. You are supposed to be using therapeutic communication during the procedure, not just going through the motions of the bath. You seem to have difficulty communicating. Maybe you should think about a career other than nursing.” This incident happened many years ago. The student to whom it happened was me, one of the co-authors. I was shocked that I had been judged so soon and so harshly. The incident made me so angry that I determined I would not give this instructor the satisfaction of my leaving nursing. But the story could have ended differently. After many years of clinical nursing and teaching, I have never forgotten the experience and how I felt. I wonder how many other students or new graduates, struggling to gain confidence and competence in the clinical area, withdraw from nursing because of too harsh judgment that comes too soon. Many nurse educators consider clinical teaching the most difficult part of the nurse educator role. And the most difficult part of clinical teaching may be the process of clinical evaluation of students. It is the clinical instructor’s responsibility not only to keep the students’ patients safe, providing them with excellent nursing care, but also to facilitate the students’ learning. Thus, the instructor constantly moves between responsibilities to the patients and the students—and also the nursing and medical staff on the unit, who have the ultimate responsibility for the patients’ care. It is critical to create a learning environment where students feel comfortable and also to monitor students’ progress to ensure that they are practicing responsibly. Students need time to learn new skills and they learn at different rates and in different ways. If students are slow learners, should they be given more time to demonstrate satisfactory performance than students who appear to learn required skills readily? Perhaps given adequate time for learning, these students will eventually be successful. Or should the instructor be able to know early on whether a student will succeed? If an instructor allows “weak” students to progress into the next course, hoping that they will eventually gain the needed skills, how long should these students be allowed to continue? Is it fair to allow students to progress almost to graduation and then decide that they cannot pass and must leave the program? Or is it better to decide early that a particular student will not succeed? These are all difficult questions for even an experienced nurse educator to answer. And for novice educators, clinical evaluation of students can be a scary and challenging process. Stories in the following sections from participants in the Clinical Nurse Educator Academy illustrate the difficulty of the evaluation process for novice nurse educators, as well as my own, along with the importance of the process for students’ learning (Cangelosi, Crocker, & Sorrell, 2009). The stories are focused around important aspects of carrying out clinical evaluations: respect, communication, a safe learning environment, collaborative goal development, and helping students see the big picture of their role as students moving toward professional nursing practice. It is important to remember that you may feel like a novice as an educator, but for the student, the feeling of being a novice in the clinical environment may be overwhelming. Fear may keep students from performing as they would once they have more confidence. It is important to assure students that you respect their individual differences in learning and that you will guide them toward situations that will help them build self-confidence. Hannah, a nurse participating in the nurse academy whose comment is at the beginning of this chapter, noted a critical element that should be part of any clinical evaluation—respect for the student as a person and as a learner: Changing roles from an expert clinician to a novice nurse educator definitely will cause me to self-reflect.… I think about all of the instructors I had during my clinical experiences and none were perfect. I am not sure there is such a thing, yet I have learned from all of them. Each instructor had valuable information to share. I was eager for the knowledge. I watched and absorbed every little detail. There was only one instructor who left a negative impression in my memory. I will never forget her as she was extremely critical of all of the students and made us feel inferior. She would yell and belittle us in front of the other students.… I firmly believe that all people need to feel respected and valued. Since most beginning students and new graduate nurses feel very vulnerable in the unfamiliar clinical environment, what they perceive as a lack of respect from an instructor can have a profound impact on their self-confidence. Cara’s memories of an incident where she felt a lack of respect from faculty have stayed with her for many years: During my senior year, I overheard a group of three nursing faculty discussing and laughing about a particular student’s actions.… My respect for those instructors diminished. I felt badly for the student whose name they mentioned. We were all working so hard and looking for guidance. That could have been any one of us. We were students who were searching for role models to help mentor us and teach us about what it means to be a nurse. I was shocked by such unprofessional behavior exhibited by the esteemed faculty I had highly respected. I knew I didn’t want to be that type of nurse. Respect for individuals and their learning styles includes the need to apply standards in a way that allows for individual variation. Sabrina noted the importance of a nonjudgmental attitude: I think being nonjudgmental is a critical trait.… You need to encourage students to ask questions and be honest about their capabilities and areas for growth. If you are judgmental, you will shut students down and they may get into trouble. As a clinical educator, you work closely with individual students and new graduate nurses, so you are in an excellent position to see qualities and limitations in them that others might not see. You want them to feel at their best when their performance is being evaluated. You can make an important difference by pointing out to an individual a particular strength that you note. For example, Lisa commented: I had an RN supervisor who saw in me something I was not aware I possess—leadership abilities. When you see yourself not merely as someone to judge the students or new graduates, but as someone who is there to help them recognize their strengths and limitations, you will also feel more comfortable in your novice educator role, as students will see you as someone to guide them, not to judge them. In the fast-paced clinical environment, it is easy to lose sight of how important it is to take time to communicate with students and new graduate nurses about how you view their performance on a continuum of learning. The educator must be observant and intuitive to know the best time to communicate this information. It is also important to deliver the message compassionately, respecting the student’s right to privacy and dignity. Cara described an incident when she did not receive the explanations she needed about her performance of giving an injection. It is evident that the incident impacted her ability to feel confident about her learning: I remember back to my days in clinical education when everything revolved around the nursing faculty. They sat upon that pedestal where everything they did you believed was worth role modeling. The atmosphere was not one that facilitated or fostered new or creative ideas. You did it their way or you failed. I remember my first IM [intramuscular] injection; the instructor grabbed my hand and assisted me. I felt disheartened. There was no communication from the instructor if I was doing something wrong or if she did that with all nurses on their first shot. How frustrated I was, never knowing what she was going to do to me next. Perhaps the instructor meant to be helpful by reaching in to assist with the injection. But it is clear from Cara’s description of the incident that she needed more feedback from the instructor about how she was doing and what she should do differently next time. Students who do not receive helpful feedback from teachers may compare themselves too harshly with those who are more advanced in their studies. This may lead to a level of decreased self-confidence that may have a negative impact on clinical performance (Plakht, Shiyovich, Nusbaum, & Raizer, 2013). It is important for students and new graduate nurses to realize that everyone makes mistakes but that it is important to address the errors and learn from them. I once observed a clinical instructor warning her students about the dangers of making a medication error. She warned the students: “If I ever made a medication error, I think I would have to leave nursing.” Her comments sent chills through me, as I had already made several medication errors in my practice. Fortunately, they had not created serious harm and I learned a great deal from my errors. But how would these students feel if they made a medication error? Would the instructor’s words stay with them to create a serious lack of self-confidence or even cause them to leave nursing? In the process of clinical evaluation, it is important not only to point out errors that a student or nurse may be making but also to help them see how to remedy the situation. If individuals fear that by reporting an error they will be punished, they may hide their error. Thus, it is important to create a learning environment that feels safe for communicating errors when they occur. Cara emphasized this, calling out for a “safe harbor” for learning: I think for any learning to take place you have to create a safe environment. This includes respecting students as people.… Once a safe harbor is provided, students feel more at ease that their character will not be judged or torn down. Providing a safe environment allows the student to feel more at ease in coming to you and asking questions. If I know a student is performing a skill for the first time, together we review the steps in that procedure. Depending on the comfort level of the student, he or she may only need me there for support and to catch them if they should stumble. Other students need to focus and think totally about the skill while I will talk with the patient. This is being in tune with their verbal and nonverbal communication. In the process of creating a safe environment for students, it is important to consider how assessment from clinical nurses on the unit may affect students. Clinicians who have many years of vast experience may forget how much they had to learn along the way and may be impatient with students who do not seem to be mastering skills quickly enough. As the nurse educator on the unit, it is helpful to develop a positive relationship with the staff, including them in your goals for the students. Lynn pointed out how she addresses this: I may have to stand up for my students if issues arise with staff or patients. I want to listen, understand, encourage, and support my students. To put it best, I want to be available. One educator described a very disturbing incident that had happened with a student on a neurosurgical unit where the head nurse did not want students, but was required to have them by the hospital supervisor: I was responsible for two different groups of students on two different floors so I had to run up and down the stairs often to make sure that I was available when students needed me. At one point, I walked on to the neuro unit to see a patient’s gown being hurled into the hallway as the head nurse stormed out and marched down the hall to the nurses’ station. My student, standing by the patient’s bed, looked as if he were in shock. When I took him aside to find out what had happened, he explained that the patient, who was being evaluated for a possible sub-arachnoid hemorrhage, was on complete bed rest. He had completed the bed bath and then helped his patient into a clean gown. When the head nurse entered, she was furious, saying that the student did not understand what complete bed rest meant and that he had possibly caused harm by allowing the patient to move around in bed. This explanation seemed to make no sense at all. Surely there must have been some other rationale for why the head nurse had acted toward the student as she had. I tried to get an explanation from her but she just walked away. I felt that I needed to protect future students from such harsh behavior so I reported the incident to the hospital supervisor, who seemed appreciative that I had brought it to her attention. The supervisor scheduled a conference for her, the head nurse, and me to discuss the situation. On the day scheduled for the conference, I was terrified at the prospect of confronting this nurse again! But at the last minute, she called the supervisor to say something had come up on the unit and she wouldn’t be able to get away to meet with me. I never saw her again. It is important for students to know your expectations of what they should accomplish in a course, but it also is important for you to know students’ individual goals that they want to meet. As a clinical nurse educator, you will be responsible for guiding students to meet objectives for the course. However, course objectives are broad and meant to apply to all students in the course. It is important to remember that students are each at a different learning point in the course and set different goals for themselves. I remember one clinical group of new students that I took to a nursing home for their first experience. I had them wait in the hallway while I went in the room of an elderly man to see if he would agree to have me bring in the students to talk with him. After chatting with him a few minutes, I returned to the student group to tell them it would be fine for us to go into the patient’s room. One student stared at me, amazed. “How do you do that?” she asked. “How do I do what?” I responded, confused by her question. “Talk to a stranger like that! How do you know what to say when you go into a stranger’s room like that? I don’t think I can ever do that!” This incident helped me remember that many young students have never been in situations where they have to interact in a health professional–patient role and that many are even unfamiliar with relating to older adults. This student’s response made me realize that one goal I needed to help her with that semester was to feel comfortable in initiating focused communications with different patients—and she did accomplish this! Students are used to articulating their goals in formal terms, as required in many of their classes. But as in the incident just described, students often have personal goals that they want to meet, for example, to enhance their confidence and skill in therapeutic communication, gain an understanding of cultural aspects of patient care, or improve organizational skills in caring for more than one patient at a time. It is important to structure opportunities for sharing these individual goals. Cara described how she approached this with her students: Providing clear guidelines, direction, and support are other teaching methods students need. Students, like adult learners, use stories and lessons learned to aid in their own growth. It is amazing to see the light bulbs go on; those “a-ha” moments. During one of my evaluation summaries from nursing students this past year, they requested more real-life stories from clinical practice. They enjoy sharing their clinical stories in post conference. Students learn as they teach one another. They are able to benefit from the clinical experiences of others. A goal of mine is to determine how much room the student needs to grow without feeling smothered. The difficult part, the real art of teaching, is finding that magic balance between giving them enough information to make their own discoveries without handing them everything on a silver platter. Providing students with small steps of freedom in their new practice provides them with an increasing self-confidence and reassurance that they are acquiring necessary and useful skills.
Clinical Evaluation of Students: Where Does Learning Stop and Evaluation Begin?
THE STORIES
Respect for Persons and Different Processes of Learning
Compassionate and Constructive Communication
Creating a Safe Environment for Mistakes
Developing Collaborative Goals
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