13
CLINICAL EVALUATION PROCESS
Nursing as a practice discipline requires development of higher level cognitive skills, values, and psychomotor and technical skills for care of patients across settings. Acquisition of knowledge alone is not sufficient; professional education includes a practice dimension in which students develop competencies for care of patients and learn to think like professionals. Through clinical evaluation, the teacher arrives at judgments about the students’ competencies—their performance in practice. This chapter describes the process of clinical evaluation in nursing; in Chapter 14, Clinical Evaluation Methods, specific clinical evaluation methods are presented.
Outcomes of Clinical Practice
There are many outcomes that students can achieve through their clinical practice experiences. In clinical courses, students acquire knowledge and learn about concepts and evidence to guide their patient care. They have an opportunity to transfer learning from readings, face-to-face classes and discussions, online classes, simulations, and other experiences to care of patients.
Clinical experiences provide an opportunity for students to use research findings and other evidence to make decisions about interventions and other aspects of patient care. In the practice setting, they learn the process of evidence-based nursing and how to translate evidence to patient care. They also need to acquire knowledge, skills, and attitudes for improving the quality of healthcare (Altmiller & Armstrong, 2017; Dolansky & Moore, 2013; Drenkard, 2015; Interprofessional Education Collaborative Expert Panel, 2016; Johnson, Drenkard, Emard, & McGuinn, 2015; Phillips, Stalter, Dolansky, & Lopez, 2016; Quality and Safety Education for Nurses [QSEN], 2019). In practice, students deal with ambiguous patient situations and unique cases that do not fit the textbook description; this requires students to think critically about what to do. For this reason, clinical practice, whether in the patient care setting or simulation laboratory, is important for developing higher level cognitive skills and for learning to arrive at clinical judgments based on available 254information (Manetti, 2018, 2019; Victor, Ruppert, & Ballasy, 2017). Clinical experiences present problems and situations that may not lend themselves to resolution through the application of research findings and theories learned in class and through one’s readings. When faced with problems in clinical practice that are not clear-cut or easily solved, students have an opportunity to develop their thinking and clinical judgment skills.
Through practice experiences with patients and in learning and simulation laboratories, students develop their psychomotor skills, learn how to use technology, and gain necessary skills for implementing nursing and other interventions. This practice is essential for initial learning, to refine competencies, and to maintain them over a period of time. Through practice students also learn the realities of caring for patients in varied healthcare environments. As healthcare systems and patients rely increasingly on information technology, students must acquire informatics competencies and be able to use new technologies, such as telehealth and digital health tools, as they are introduced into practice.
Having technical skills, though, is only one aspect of professional practice. In caring for patients and working with nurses and other healthcare providers, students gain an understanding of how professionals approach their patients’ problems, how they interact with each other, and what behaviors are important in carrying out their roles and working as a team in the practice setting. Learning to collaborate with other healthcare professionals and function effectively on nursing and interprofessional teams are critical to providing quality and safe care (Horsley et al., 2016; Interprofessional Education Collaborative Expert Panel, 2016; Sullivan, Kiovsky, Mason, Hill, & Dukes, 2015). Clinical learning activities provide an opportunity for students to develop their individual and team communication skills and learn how to collaborate with others.
Practice as a professional is contingent not only on having knowledge to guide decisions but also on having a value system that recognizes the worth, dignity, and rights of patients and others in the healthcare system. As part of this value system, students need to develop cultural competence and gain the knowledge and attitudes essential to provide multicultural healthcare. As society becomes more diverse, it is critical for nursing students to become culturally competent (Blanchet Garneau, 2016; de Castro, Dyba, Cortez, & Pe Benito, 2019; Dyches, Haynes-Ferere, & Haynes, 2019; Flood & Commendador, 2016). Much of this learning can occur in clinical practice as students care for culturally diverse patients and communities and through simulations in which they can explore cultural differences. Clinical experiences help students develop competencies in patient-centered care: respecting patients’ preferences, values, and needs; recognizing patients as partners in care; providing compassionate care; continuously coordinating care; and advocating for patients (Bentley, 255Engelhardt, & Watzak, 2014; Horsley et al., 2016). These core competencies, needed by all healthcare professionals, are developed in clinical practice.
Another outcome of clinical practice is developing knowledge, skills, and values to continuously improve the quality and safety of healthcare (Altmiller & Armstrong, 2017; Drenkard, 2015; Johnson et al., 2015; Phillips et al., 2016; QSEN, 2019). Nursing students need to learn quality-improvement methods and have experience with them as part of their clinical practice. They also need to understand their role in creating a safe healthcare system for patients and a safety culture in every clinical setting, learn about healthcare errors and how to prevent them, and value the importance of error reporting. These are competencies that can be developed in simulation and clinical practice.
Some clinical courses focus on management and leadership outcomes. For those courses, clinical practice provides learning opportunities for students to manage groups of patients, provide leadership in the healthcare setting, and learn how to delegate, among other competencies.
In clinical practice, students learn to accept responsibility for their actions and decisions about patients. They also should be willing to accept errors in judgment and learn from them. These are important outcomes of clinical practice in any nursing and health professions program.
Another outcome of clinical practice is learning to learn. Professionals in any field are learners throughout the duration of their careers. Continually expanding knowledge, developments in healthcare, and new technology alone create the need for lifelong learners in nursing. In clinical practice, students are faced with situations of which they are unsure; they are challenged to raise questions about patient care and seek further learning. In nursing courses as students are faced with gaps in their learning, they should be guided in the self-assessment process, directed to resources for learning, and supported by the teacher. All too often students are hesitant to express their learning needs to their teachers for fear of the effect it will have on their grade or on the teacher’s impression of the student’s competence in clinical practice.
These outcomes of clinical practice are listed in Exhibit 13.1. Integrated in this list are the core competencies needed by all healthcare professionals: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Dolansky & Moore, 2013; QSEN, 2019). The outcomes provide a framework for faculty members to use in planning their clinical courses and deciding how to assess student performance. Not all outcomes are applicable to every nursing course; for instance, some courses may not call for the acquisition of technological or delegation skills, but overall, most courses will move students toward achievement of these outcomes as they progress through the nursing program.
256EXHIBIT 13.1 OUTCOMES OF CLINICAL PRACTICE IN NURSING PROGRAMS
• Acquire concepts, theories, and other knowledge for clinical practice.
• Use research and other evidence in clinical practice.
• Develop higher level thinking and clinical judgment skills.
• Develop psychomotor and technical skills, competence in performing other types of interventions, and informatics competencies.
• Communicate effectively with patients, families, communities, and others in the healthcare system.
• Collaborate with and lead interprofessional teams.
• Develop values and knowledge essential for providing patient-centered care to a culturally and ethnically diverse patient population.
• Develop knowledge, skills, and values essential for continuously improving the quality and safety of healthcare.
• Demonstrate leadership skills and behaviors of a professional.
• Accept responsibility for actions and decisions.
• Accept the need for continued learning and self-development.
Concept of Clinical Evaluation
Clinical evaluation is a process by which judgments are made about learners’ competencies in practice. This practice may involve care of patients, families, and communities; other types of experiences in the clinical setting; simulated experiences; and performance of varied skills. Most often, clinical evaluation involves observing performance and arriving at judgments about the student’s competence. Judgments influence the data collected, that is, the specific types of observations made to evaluate the student’s performance, and the inferences and conclusions drawn from the data about the quality of that performance. Teachers may collect different data to evaluate the same outcomes, and when presented with a series of observations about a student’s performance in clinical practice, there may be little consistency in their judgments about how well that student performed.
Clinical evaluation is not an objective process; it is subjective—involving judgments by the teacher and others involved in the process. As discussed in Chapter 1, Assessment and the Educational Process, the teacher’s values influence evaluation. This is most apparent in clinical evaluation, where our values influence the observations we make of students and the judgments we make about the quality of their performance. Thus, it is important for teachers to be aware of their own values that might bias their judgments of students.
257This is not to suggest that clinical evaluation can be value-free; the teacher’s observations of performance and conclusions always will be influenced by her or his values. The key is to develop an awareness of these values so as to avoid their influencing clinical evaluation to a point of unfairness to the student. For example, if the teacher prefers students who initiate discussions and participate actively in conferences, this value should not influence judgments about students’ competencies in other areas. The teacher needs to be aware of this preference to avoid an unfair evaluation of other dimensions of the students’ clinical performance. Or, if the teacher is used to the fast pace of most acute care settings, when working with beginning students or someone who “moves slowly,” the teacher should be cautious not to let this prior experience influence expectations of performance. Clinical educators should examine their own values, attitudes, and beliefs so that they are aware of them as they teach and assess students’ performance in practice settings.
Clinical Evaluation Versus Grading
Clinical evaluation is not the same as grading. In evaluation, the teacher makes observations of performance and collects other types of data, then compares this information to a set of standards to arrive at a judgment. From this assessment, a quantitative symbol or grade may be applied to reflect the evaluation data and judgments made about performance. The clinical grade, such as pass–fail or A through F, is the symbol used to represent the evaluation. Clinical performance may be evaluated and not graded, such as with formative evaluation or feedback to the learner, or it may be graded. Grades, however, should not be assigned without sufficient data about clinical performance.
Norm- and Criterion-Referenced Clinical Evaluation
Clinical evaluation may be either norm referenced or criterion referenced, as described in Chapter 1, Assessment and the Educational Process. In norm-referenced evaluation, the student’s clinical performance is compared with that of other students, indicating that the performance is better than, worse than, or equivalent to that of others in the comparison group or that the student has more or less knowledge, skill, or ability than the other students. Rating students’ clinical competencies in relation to others in the clinical group—for example, indicating that the student was “average”—is a norm-referenced interpretation.
In contrast, criterion-referenced clinical evaluation involves comparing the student’s clinical performance with predetermined criteria, not to the performance of other students in the group. In this type of clinical evaluation, the criteria are known in advance and used as the basis for evaluation. Indicating that the student has met 258the clinical outcomes or achieved the clinical competencies, regardless of how other students performed, represents a criterion-referenced interpretation.
Formative and Summative Clinical Evaluation
Clinical evaluation may be formative or summative. Formative evaluation in clinical practice provides feedback to learners about their progress in meeting the outcomes of the clinical course or in developing the clinical competencies. The purposes of formative evaluation are to enable students to develop further their clinical knowledge, skills, and values; indicate areas in which learning and practice are needed; and provide a basis for suggesting additional instruction to improve performance. With this type of evaluation, after identifying the learning needs, instruction is provided to move students forward in their learning. Formative evaluation, therefore, is diagnostic; it should not be graded (Brookhart & Nitko, 2019). For example, the clinical teacher or preceptor might observe a student perform wound care and give feedback on changes to make with the technique. The goal of this assessment is to improve subsequent performance, not to grade how well the student carried out the procedure.
Summative clinical evaluation, however, is designed for determining clinical grades because it summarizes competencies the student has developed in clinical practice. Summative evaluation is done at the end of a period of time, for example, at midterm or at the end of the clinical practicum, to assess the extent to which learners have achieved the clinical outcomes or competencies. Summative evaluation is not diagnostic; it summarizes the performance of students at a particular point in time. For much of clinical practice in a nursing education program, summative evaluation comes too late for students to have an opportunity to improve performance. Any protocol for clinical evaluation should include extensive formative evaluation and periodic summative evaluation. Formative evaluation is essential to provide feedback to improve performance while practice experiences are still available.
Fairness in Clinical Evaluation
Considering that clinical evaluation is not objective, the goal is to establish a fair evaluation system. Fairness requires that:
1. The clinical teacher identify his or her own values, attitudes, beliefs, and biases that may influence the evaluation process.
2. Clinical evaluation is based on predetermined outcomes or competencies.
3. The teacher develops a supportive clinical learning environment.
259Identify One’s Own Values
Teachers need to be aware of their personal values, attitudes, beliefs, and biases, which may influence the evaluation process. These can affect both the data collected about students and the judgments made about performance. In addition, students have their own set of values and attitudes that influence their self-evaluations of performance and their responses to the teacher’s evaluations and feedback. Students’ acceptance of the teacher’s guidance in clinical practice and information provided to them for improving performance is affected by their past experiences in clinical courses with other faculty. Students may have had problems in prior clinical courses, receiving only negative feedback and limited support from the teacher, staff members, and others. In situations in which student responses inhibit learning, the teacher may need to intervene to guide students to be more self-aware concerning the students’ own values and the effect they are having on learning.
Base Clinical Evaluation on Predetermined Outcomes or Competencies
Clinical evaluation should be based on preset outcomes or clinical competencies that are then used to guide the evaluation process. Without these, neither the teacher nor the student has any basis for evaluating clinical performance. What are the outcomes of the clinical course to be met or what competencies should the student achieve in this clinical practicum? These outcomes or competencies provide a framework for educators to use in observing performance and for arriving at judgments about achievement in clinical practice. For example, if the competencies relate to developing communication skills, then the learning activities, whether in the patient care setting or as part of a simulation, should assist students in learning how to communicate. The teacher’s observations and subsequent assessment should focus on communication behaviors, not on other competencies unrelated to the learning activities.
Develop a Supportive Learning Environment
It is up to the teacher to develop a supportive learning environment in which students view the teacher as someone who will facilitate their learning and development of clinical competencies. Students need to be comfortable asking faculty and staff members questions and seeking their guidance rather than avoiding them in the clinical setting. A supportive environment is critical to effective assessment because students need to recognize that the teacher’s feedback is intended to help them improve performance. Developing a “climate” for learning is also important because clinical practice is stressful for students 260(Bagcivan, Cinar, Tosun, & Korkmaz, 2015; Bhurtun, Azimirad, Saaranen, & Turunen, 2019; Blomberg et al., 2014; Suresh, Matthews, & Coyne, 2013; Zieber & Williams, 2015). Many factors influence the development of this learning climate. The clinical setting needs to provide experiences that foster student learning and development. Staff members need to be supportive of students; work collaboratively with each other, students, and the clinical teacher; and communicate effectively, both individually and as a team. Most of all, trust and respect must exist between the teacher and the students.
Student Stress in Clinical Practice
There have been a number of studies in nursing education on student stress in the clinical setting. Some of the stresses students have identified are:
• The fear of making a mistake that would harm the patient
• Having insufficient knowledge and skills for patient care
• Changing patient conditions and uncertainty about how to respond
• Being unfamiliar with the staff, policies, and other aspects of the clinical setting
• Caring for difficult patients
• Having the teacher observe and evaluate clinical performance
• Interacting with the patient, the family, nursing staff, and other healthcare providers
Learning in the clinical setting is a public experience. Students cannot hide their lack of understanding or skills as they might in class or in an online discussion. In clinical practice, the possibility exists for many people to observe the student’s performance—the teacher, patient, family members, peers, nursing staff, and other healthcare providers. Being observed and evaluated by others is stressful for students in any healthcare field.
The potential stress that students might experience in clinical practice reinforces the need for faculty members to be aware of the learning environment they set when working with students in a clinical course. The student is a learner, not a nurse, although some educators, preceptors, and other providers expect students to perform at an expert level without giving them sufficient time to practice and refine their performance (Oermann, Shellenbarger, & Gaberson, 2018). Simulated experiences may be effective in reducing some of the anxieties students experience by allowing them to practice their skills, both cognitive and psychomotor, prior to care of patients.
261Feedback in Clinical Evaluation
For clinical evaluation to be effective, the teacher should provide continuous feedback to students about their performance and how they can improve it. Feedback is the communication of information to students, based on the teacher’s assessment, that enables students to reflect on their performance, identify continued learning needs, and decide how to meet them (Bonnel, 2008). Feedback may be verbal, by describing observations of performance and explaining what to do differently, or visual, by demonstrating correct performance. Feedback should be specific and accompanied by further instruction from the teacher or by working with students to identify appropriate learning activities. The ultimate goal is for students to progress to a point at which they can judge their own performance, identify resources for their learning, and use those resources to further develop competencies. Bonnel (2008) emphasized that for feedback to be useful, students need to reflect on the information communicated to them and take an active role in incorporating that feedback in their own learning (p. 290).
Students must have an underlying knowledge base and beginning skills to judge their own performance. Brookhart and Nitko (2019) suggested that feedback on performance also identifies the possible causes or reasons why the student has not mastered the learning outcomes. Sometimes, the reason is that the student does not have the prerequisite knowledge and skills for developing the new competencies. As such it is critical for clinical teachers and preceptors to begin their interactions with students by assessing whether students have learned the necessary concepts and skills and, if not, to start there.
Principles of Providing Feedback as Part of Clinical Evaluation
There are five principles for providing feedback to students as part of the clinical evaluation process. First, the feedback should be precise and specific. General information about performance, such as “You need to work on your assessment” or “You need more practice in the simulation center,” does not indicate which behaviors need improvement or how to develop them. Instead of using general statements, the teacher should indicate what specific areas of knowledge are lacking, where there are problems in thinking and clinical judgments, and what particular competencies need more development. Rather than saying to a student, “You need to work on your assessment,” the feedback would be more effective if the teacher identified the specific areas of data collection omitted and the physical examination techniques that need improvement. Specific feedback is more valuable to learners than a general description of their behavior.
Second, for procedures, use of technologies, and psychomotor skills, the 262teacher should provide both verbal and visual feedback to students. This means that the teacher should explain first where the errors were made in performance and then demonstrate the correct procedure or skill. Research suggests that physically guiding learners in how to perform the procedure or skill improves their accuracy (Soderstrom & Bjork, 2015). This should be followed by the student practicing the skill with the teacher guiding performance. By allowing immediate practice, with the teacher available to correct problems, students can more easily use the feedback to further develop their skills.
Third, feedback about performance should be given to students at the time of learning or immediately following it. Giving prompt feedback is one of the seven core principles for effective teaching in undergraduate programs (Chickering & Gamson, 1987). Providing prompt and rich feedback is equally important when teaching graduate students, nurses, and other learners regardless of their educational level. The longer the period of time between performance and feedback from the teacher, the less effective the feedback (Oermann et al., 2018). As time passes, neither student nor teacher may remember specific areas of clinical practice to be improved. This principle holds true whether the performance relates to clinical judgment or other cognitive skills, a procedure or technical skill, or an attitude or value expressed by the student, among other areas. Whether working with a group of students in a clinical setting, communicating with preceptors about students, or teaching an online course, the teacher needs to develop a strategy for giving focused and prompt feedback to students and following up with further discussion as needed. Recording short notes for later discussion with individual students may help the teacher remember important points about performance.
Fourth, students need different amounts of feedback and positive reinforcement. In beginning practice and with clinical situations that are new to learners, most students will need frequent and extensive feedback. As students progress through the program and become more competent, they should be able to assess their own performance and identify personal learning needs. Some students will require more feedback and direction from the teacher than others. As with many aspects of education, one approach does not fit all students. Feedback should always be given to students in a private area.
One final principle is that feedback should be diagnostic. This means that after identifying areas in which further learning is needed, the teacher’s responsibility is to guide students so that they can improve their performance. Altmiller (2016) emphasized the importance of being attentive to how the feedback is delivered: the teacher should identify the feedback as an opportunity for student learning and include options for improvement. The process is cyclical—the teacher observes and assesses performance, gives students feedback about that performance, and then guides their learning and practice so they can become more competent.
263Gigante, Dell, and Sharkey (2011) proposed a five-step process for giving feedback to students:
1. Identify the expectations for the student. Students need to know what is expected of them in the clinical practicum.
2. Set the stage for the student to receive feedback from the teacher and others involved in the learning situation. The authors recommend beginning with this phrase, “I am giving you feedback” because then students realize that the information is to help them improve performance.
3. Begin the interaction by asking students to assess their own performance, which encourages reflection and learning.
4. Describe how the student is performing based on specific observations of behaviors, which should be shared. It is important to provide concrete examples of performance and describe specifically how the learner can improve.
5. Ask for input from the learner. In some cases, such as when there are concerns about not achieving at a satisfactory level in the course, a written plan for improvement should be developed with consequences outlined.
Clinical Outcomes and Competencies
There are different ways of specifying the outcomes to be achieved in clinical practice, which in turn provide the basis for clinical evaluation. These may be stated in the form of outcomes to be met or as competencies to be demonstrated in clinical practice. Regardless of how these are stated, they represent what is evaluated in clinical practice.
The outcomes of clinical practice offered in Exhibit 13.1 can be used for developing specific outcomes or competencies for a clinical course. Not all clinical courses will have outcomes in each of these areas, and in some courses, there may be other types of competencies unique to practice in that clinical specialty. Some faculty members identify common outcomes or competencies that are used for each clinical course in the program and then level those to demonstrate their progressive development through the nursing program (Billings & Halstead, 2016). For example, with this model, each course would have an outcome on communication. In a beginning clinical course, the outcome might be, “Identifies verbal and nonverbal techniques for communicating with patients.” In a later course in the curriculum, the communication outcome might focus on the family and working with caregivers, for example, “Develops interpersonal relationships with families and caregivers.” Then in the community health course the outcome might be, “Collaborates with other providers, interdisciplinary groups, and community organizations.”
264As another approach, some faculty members state the outcomes broadly and then indicate specific behaviors students should demonstrate to meet those outcomes in a particular course. For example, the outcome on communication might be stated as “Communicates effectively with patients and on intra- and interprofessional teams.” Examples of behaviors that indicate achievement of this outcome in a course on care of children include, “Uses appropriate verbal and nonverbal communication based on the child’s age, developmental status, and health condition” and “Interacts effectively with parents, caregivers, and the interprofessional team.” Generally, the outcomes or competencies are then used for developing the clinical evaluation tool or rating form, which is discussed in Chapter 14, Clinical Evaluation Methods.
Regardless of how the outcomes are stated for a clinical course, they need to be specific enough to guide the evaluation of students in clinical practice. An outcome such as “Use the nursing process in care of children” is too broad to guide evaluation. More specific outcomes such as “Carries out a systematic assessment of children reflecting their developmental stage,” “Evaluates the impact of health problems on the family,” and “Identifies resources for managing the child’s care at home” make clear to students what is expected of them in clinical practice.
Competencies are the abilities to be demonstrated by the learner in clinical practice. Competencies are the knowledge, skills, and attitudes that students need to develop; they provide the foundation for evaluation (Sullivan, 2016). For nurses in practice, these competencies reflect the expected level of performance for caring for patients in the healthcare setting. Competencies for nurses are assessed on hire and on an ongoing basis, usually annually, validating that nurses are competent to practice (Levine & Johnson, 2014). Caution should be exercised in developing clinical outcomes and competencies to avoid having too many for evaluation, considering the number of learners for whom the teacher is responsible, types of clinical learning opportunities available, and time allotted for clinical learning activities. In preparing outcomes or competencies for a clinical course, teachers should keep in mind that they need to collect sufficient data about students’ performance of each outcome or competency specified for that course. Too many outcomes make it nearly impossible to collect enough data on the performance of all of the students in the clinical setting whether they are in a small group with a faculty member on site or are working one-to-one with a clinician. Regardless of how the evaluation system is developed, the clinical outcomes or competencies need to be realistic and useful for guiding the evaluation.
Summary
Through clinical evaluation, the teacher arrives at judgments about students’ performance in clinical practice. The teacher’s observations of performance should focus on the outcomes to be met or competencies to be developed in the clinical course. These provide the framework for learning in clinical practice and the basis for evaluating performance.
265Although a framework such as this is essential in clinical evaluation, teachers also need to examine their own beliefs about the evaluation process and the purposes it serves in nursing. Clarifying one’s own values, beliefs, attitudes, and biases that may affect evaluation is an important first step. Recognizing the inherent stress of clinical practice for many students and developing a supportive learning environment are also important. Other concepts of evaluation, presented in Chapter 1, Assessment and the Educational Process, apply to clinical evaluation. Specific methods for clinical evaluation are described in Chapter 14, Clinical Evaluation Methods.
