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DEVELOPING A CLINICAL IMAGINATION
IN OUR INTERVIEWS and from the Carnegie-NSNA survey responses, students reported that on the whole their experience of learning in the classroom did not develop their clinical imagination. As a student responding to the survey noted with dismay, “I don’t feel you get enough practice and guidance in the classroom that best fits how the settings will be in the clinical setting.” Our classroom observations corroborated the students’ views that clinical integration is missing in most nursing classrooms.
“I feel that much of what we learn in the classroom,” wrote another student on the Carnegie-NSNA survey, “has no direct implication with the day-to-day clinical setting. I wish there was more hands-on [practice] in the classroom setting [with] how to deal with a client and more pathophysiology in the clinical setting.” Another student pinpointed difficulties students and teachers face in the classroom when trying to teach and learn nursing practice: “The classroom tries to inform us of the skills and knowledge we will need in the clinical experience, but the reality of the clinical experience is hard to obtain or explain in a classroom setting. There is a great difference between what is taught in the classroom and ‘real-world’ practice.”
In contrast, Lisa Day’s students point out that her classroom simulation of an unfolding case and her clinical questions for students integrate what they learn in the classroom with what they learn in clinical settings—“real-world practice.” Developing students’ clinical imagination helps them both recognize significant changes in a patient’s condition and make a persuasive argument for a change in therapy. Day creates opportunities for students to rehearse using clinical reasoning in transition, following patient changes that require them to think in a number of ways in order to respond appropriately. Similarly, she uses the students’ involvement in cases to extend their imagination about practice to working with the health care team. For her students, the clinical learning thus flows back and forth from the hospital and other clinical situations to the classroom. In large part, this happens because she considers aspects of practice that the students must prepare for, such as learning to stay open and learning to make a case.
Learning to Stay Open
For Day, teaching critical care and medical-surgical nursing in the hospital setting cannot be separated into technical mastery plus clinical judgment and ethical comportment. The three are intertwined. Technical mastery and knowledge are necessary but not sufficient for becoming a good nurse; the nurse’s therapeutic responses must be generated by the patient’s concerns and clinical situation. In other words, the nurse must stay open to changes in the patient’s responses over time and recognize the clinical implications of any trends in the patient’s vital signs, urinary output, or other relevant aspects of patient changes.
In her classroom, Day uses the unfolding case to drive home the import of attention to changes in a patient’s condition over time, a key learning point for nursing practice. Because it is the nurse who spends the most time with the patient, a crucial part of nursing practice is detecting patient changes and then adjusting nursing care accordingly, which may include alerting physicians in order to prompt adjustments or changes in medical treatments. It is important that nurses avoid ritualized responses and routines so they are always open to the possibility that the situation may call for something different.
Clinical teachers must constantly help students master the skilled know-how of practice while at the same time encourage them to stay open to what is unknown, always ready to have their assumptions turned around. Students need to learn how to assess the patient’s immediate history to account for changes in the patient’s current condition and at the same time reason across real-time transitions as the patient’s condition and concerns continue to evolve. Thus nurse educators put a great deal of effort into teaching students the importance of ongoing assessment over time with attention to what is different now, and clinical faculty spend time instilling a disposition for being open, as exemplified in this exchange:
I brought the case to the student: “So what would you do next? This patient isn’t fitting the profile. The patient isn’t going along like you expected. How can you revise this plan?” And that’s the thinking piece, because we don’t want to give students blueprints but have them adjust their care to go along with the person’s current developmental stage, to go along with the cultural status of the patient, what they normally eat. So we teach the student to think in a lot of different directions instead of putting things in boxes most of the time. “This is the patient, this happens, what do you do next?” And they can’t look at their notes and memorize how to answer the question. They really have to do some thinking. How can they adjust their plan and how they can deal with the fact that what they prepared for on Monday night is not at all what they’re going to do on Tuesday?
By drawing the student’s attention to the shortcomings of a plan made the night before, the teacher in this example helped her student learn how to stay open and think in a changing situation.
Day brings the same focus on vigilant assessment and openness into the classroom: “And then we bring the patient into the unit [and say], ‘These are your first assessment findings. What else do you need to know?’ They come up with all kinds of other things. I purposely leave some things out of the assessment for them to find. They come up with all kinds of other stuff that’s missing that I didn’t really even think of or maybe isn’t essential information right at this moment, but definitely is going to make a contribution to what you know about this patient.”
The Power of Context
Day’s approach to classroom teaching suggests how contextualizing practice helps students stay open: focus on the patient and respond appropriately to a patient’s specific needs and concerns. Likewise, her goal in clinical teaching is that students focus on the patient rather than the “procedure of the day.” As students learn technical skills such as placement of a nasogastric (NG) tube, they also learn to form appropriate responses to the particular patient.
Day writes an ethics column, “Current Controversies,” for the American Journal of Critical Care. In this excerpt of a column Day wrote with Minnie Woods, a beginning nursing student working on a general surgical unit, Day illustrates the focus on the patient that she stresses with her students in the classroom as well as in clinical. Woods writes:
I was assigned to Mrs. R. She was diagnosed with a small bowel obstruction secondary to pancreatic cancer. During report they said that Mrs. R. had been overwhelmed by nausea throughout the previous night and that she needed to have an NG tube placed but that she was refusing it. My first thought was, “Thank God she’s refusing it,” because I knew that it would be my responsibility to insert it.
Since I started nursing school, I’ve been completely terrified of NG tubes and the whole idea of inserting them. I remember looking through our nursing skills book my first quarter and thinking that having such a big tube put through your nose down to your stomach seemed like one of the most terrible things I could possibly imagine, never mind actually doing it to another human being.
I sat in report that morning hoping that I was off the hook because Mrs. R. didn’t want an NG tube anyway. As soon as report was over, I checked in with the staff nurse I was working with that day. I said, “So it sounds like Mrs. R. is pretty nauseated and miserable but she’s refusing the NG tube.” “That’s right,” my nurse said, “so you better get in there and convince her that she really needs it.” I knew she was right, but I was completely dreading the whole experience.
I was already pretty familiar with Mrs. R.’s history and condition because I did lots of research the night before. When I walked in the room, Mrs. R. could barely open her eyes. She was completely overcome with nausea and was hesitant to even move. Her abdomen was really distended. Suddenly, here was this woman that I was taking care of who really needed some relief from this tremendous discomfort. I sat down and talked to Mrs. R. about the NG tube and why she didn’t want it. She was scared, of course, and wondered if it was necessary. I explained how the procedure would work, that I would do it myself with the supervision of the staff nurse, and that once we began to suction out all the fluid that was building up in her stomach she would start to feel some relief from the nausea. She agreed to go ahead with the procedure.
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