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TEACHING AND LEARNING IN CLINICAL SITUATIONS
IN OUR EFFORT to understand how nursing education prepares students to enter the social contract of the profession, we examined the student experience, augmenting classroom observation and interviews of educators and students with a review of the literature and a national survey of members of the National Student Nurses’ Association (NSNA). Of the 32,000 members who had e-mail addresses at the time of the survey, 1,648 responded (a 6 percent response rate). To see the survey instrument, go to www.carnegiefoundation.org/nursing-education/surveys. What emerged, along with particular findings about the student experience, was a view of the points at which the practice-education gap develops. We begin this chapter by looking at teaching and learning in clinical situations. In Chapter Three we examine them inside the classroom and skills labs.
High-Stakes Learning
As soon as students formally enter a nursing program, whether directly as part of community college or a diploma program, or after two years of general education in a baccalaureate program, they begin working with patients, even if it is a mannequin or a fellow student in a simulation lab. They soon enter clinical settings to learn through experience with actual patients in a variety of settings that, over time, range from community sites and patient homes to intensive care. This is what we call experiential learning, or learning from the experience of caring for patients. Students learn from the particular situations of specific patients, which is a hallmark of nursing education and what we refer to as situated learning. Both experiential learning and situated learning are central to nursing education. The student’s lay visions of nursing before entering nursing school are often far off the mark, and many students reported being stunned at the high-precision skills and knowledge nurses routinely draw on.
Although the possibility of making a mistake that could lead to the death or injury of a patient is very real and always present, patient safety is enhanced with realistic clinical simulations. Still, high-stakes learning is a necessity; only experiential learning can yield the complex, open-ended, skilled knowledge required for learning to recognize the nature of the particular resources and constraints in equally open-ended and underdetermined clinical situations. Both students and faculty are acutely aware of the dangers of putting learners in the high-risk environment of an acute care hospital. As one student put it: “It is frustrating and scary to function in the clinical setting as an inexperienced student. I often worry that I’ll miss something important in a client’s condition.” Another student captured both the excitement and the weight of responsibility that many other students expressed: “I have had the honor of being present with and learning from clients in intimate, vulnerable, scary situations. I get to regularly advocate for the underserved, especially in the hospital setting. I have access to environments I would have otherwise never been exposed to, and I have learned and grown and broadened my world perspective. I better understand how our system works, and hope someday this knowledge will help me make changes in our system.”
Understandably, nursing students fear making a mistake. In interviews and survey responses alike, the student nurses told stories of making mistakes, of reporting their errors, and their terror at the possibility of making a more dangerous error (Rodriguez, 2007). They recognize the level of responsibility of nursing practice, that a nurse’s actions could seriously harm the patient or even cause death. The high-stakes experience of the clinical setting makes nursing students aware of the need to actively think about and use their knowledge in the particular situation. If evidence or feedback from a situation does not mesh with their understanding of the situation or interpretation of the information, the student must consider new interpretations, and the clinical teacher uses questions to guide students to search for new interpretations and information.
Learning in Context
Students start their clinical learning in patient care situations that are relatively stable; they are coached and guided as they transfer skills they learned on a mannequin in a skills lab to actual patients, who may be calm or highly anxious, thin or obese, mobile or immobile. As they progress through the program, they are placed in less predictable situations, where the instructors and staff nurses allow them more responsibility and independence in performing tasks, using subtle bedside coaching or more overt coaching outside the patient’s room.
A central goal of nursing education is for the learner to develop an attuned, response-based practice and capacity to quickly recognize the nature of whole situations in terms of most pressing and least pressing concerns. As Dewey (1925/1987) suggests, experiential learning does not happen in just any condition, with just any person or on every occasion. Participation in experiential learning requires openness and readiness to improve practice over time, along with clinical reasoning (Dunne, 1993). Experiential learning depends on an environment where feedback on performance is rich and the opportunities for articulating and reflecting on the experiences are deliberately planned.
We found that clinical educators actively give feedback and make full use of the learning opportunities of the clinical situation. Typically, the clinical instructor will prepare the students, as a group, for what they will see and do the next day. During the situation, they coach the students through procedures and use the situation to deepen learning. After the experience, the students and instructor meet in postclinical conference, where the teacher prompts the students to reflect on their experience. Moreover, in the group sessions, students pool their learning, openly sharing their questions and experiences so that their classmates may benefit.
Planning and Feedback
On the night before each clinical assignment, students are expected to do extensive homework related to their assigned patients, to prepare themselves for what they will see and do in the clinical setting the next day. If a student’s patient is discharged suddenly or some other change occurs, many clinical instructors will contact their students to give them a new assignment. In preparing for clinical, students review their patient’s charts, medications, diagnoses, and complications, and they develop patient care plans for the next day. On the day of care, the students evaluate the plan in the course of care and report any changes or improvements to the plan.
Clinical instructors and students check in with each other throughout the day, the educators making sure that the students are safe and effective as they enter new areas of nursing care. Although we found that nursing students are sometimes placed in the position of observing staff nurses do a procedure, if the clinical instructor is not available the teachers usually coach the student through novel procedures, both outside and inside the patient’s room as needed, to ensure accuracy and patient safety. It is worth noting that in contrast, the first- or second-year medical student often shadows the resident or the attending physician, trying to learn through observation and questions about the medical decisions being made with the patients and families.
The nurse educator reassures nursing students that they can go over the procedure before beginning. As one clinical educator noted:
That’s just been a requirement: any new basic procedure, we are with them . . . . And so they have the opportunity to ask questions, tell us what they’re going to do before they go in and do it. At the bedside, I always tell them nursing is part acting, so you always have to act as if you really know what you’re doing at the bedside, and if you have any question in the immediate procedure (especially in our group they may freeze, they may have this brain freeze) . . . don’t hesitate, just ask if we could step out for a moment, outside the room, before you do anything.
The ambiguities of clinical situations are such that practitioners must be organized in their thinking, be able to use their knowledge, and judge when exceptions must be made and when deviations from expectations or the usual are occurring. Clinical instructors model such complex responses for their students. The patient’s situation can change rapidly, and invariably the student confronts clinical situations for which she or he is not prepared. The teacher must be open to the possibilities for teaching in each particular clinical situation, as unpredictable and varied as it might be; the teacher looks for the teachable moments, points out what is salient and what needs immediate attention, and helps students integrate and use their knowledge. However, clinical teachers must put patient safety first, at all times. The teacher thus needs to know when to guide the student through questioning and coaching and when to pull the student back and have him observe or assist another nurse, using what Lave and Wenger (1991) call “legitimate peripheral participation,” a way to teach students about high-risk situations before they are ready to actually perform in them.
Supporting Learning Through Questions
Many clinical educators engage in on-the-spot assessment of students’ understanding and knowledge in the clinical setting, asking students to answer a series of questions that are often posed in rapid succession. As one student explained, “They draw out of you what you know: ‘A prudent nurse would, dot, dot, dot, fill in the blank. This medication is for? And why are you giving it? And in the medication scheme of things, what is the most important? They’re having dialysis in an hour.’ [If I say,] ‘My patient is having dialysis,’ [the teacher asks] ‘What if they also had heart failure?’ The faculty person still wants you to answer the ‘what if’ question.… I have a profound appreciation for these questioning sessions and finding out what I don’t know.”
Clinical educators typically use what-if questions to help students extend their thinking about a clinical situation, about the ramifications of potential changes and differences in their patients. One educator explained, “I think we all use a lot of ‘what if’ questions: ‘What if this happens, what if that happens, what if the client did that?”’ For example, one teacher described a role-playing activity: “And we all get to be different people.… I got to be a sixty-five-year-old male last week and I was also a fourteen-year-old female. And then the group member behaves like the fourteen-year-old female or the sixty-five-year-old male and asks us questions.” Another teacher talked about “the what-if game” that she uses in both classroom and clinical:
I like to throw out a lot of questions like this: “What do you think if, what would be different if . . . ?” So the student will tell me a little bit about the patient and I’ll say, “What if the patient were fifty, what if the patient had hypertension, what if the patient told you that right this minute she had chest pain? What would you do?” So that’s the what-if game . . . . In clinical they love it, they actually love it. “Ask me another question”: I’ve actually had my students say that to me. “Oh, don’t go, ask me another question.”
Asking students to think about what would happen to their patients if something in their situation was different encourages the student to think about similar patients in varying circumstances, or similar circumstances with different patients. Faculty draw on other questioning strategies, as this student explained:
I had a patient who had a Whipple surgical procedure. I had just received the patient from surgery and I’d done some pre-clinical work on it and my clinical instructor said, “Well, what are your top three nursing diagnoses for this patient?” That put me right on the spot. Right when I first picked up the patient and just did an initial assessment and had to go over his first . . . I had maybe fifteen minutes and two-thirds of his medications had to be given at nine o’clock. But rather than being in gear for the meds, I had to be in gear for, “OK, what’s the bigger picture, why he’s being given these meds, what are we trying to do in these first hours post-operatively?” Your head is so filled up with things you’ve got to do, you don’t necessarily take the overall and bigger picture in a clinical setting and [the] clinical instructor is hitting you right away with, “OK, what is it we’re trying to do here?” That kind of questioning is really important.
Another student commented, “I find it very useful that [my clinical instructor] comes to the floor and asks those questions. I find that it engages me in a way that I’m going to think about.” As another student explained, “And it’s not that they’re doing it because they don’t trust us, you know; it’s not like they’re peering over our shoulders.… You know, maybe the first couple of weeks we were there, they wanted to make sure but now, they do trust us, but they also are very conscientious to check to make sure that we’re doing it right. Or before we do a procedure, they’ll ask us, “What are you going to do? When you go in there what are you going to do? Walk me through it step by step.”
As students progress through the program, the clinical teacher helps the student examine the patient’s context to help her see the whole situation, asking such questions such as, “What does this patient need most? Fear most?” and “What are the patient’s most significant concerns in terms of their family and everyday life?” Clinical teachers will ask advanced students to compare new clinical situations with prior ones, or imagine a different patient.
Developing Clinical Reasoning and Judgment
Clinical reasoning is the ability to reason about a clinical situation as it unfolds, as well as about patient and family concerns and context. It always calls for understanding the temporal nature of a case. Good nursing judgments can also never ignore the concerns and “lifeworld” of the injured or ill patient.
We observed that many clinical educators use pedagogies of contextualization, whereby they usher student nurses into a practice in which the nurse is always present for the unique patient in the situation as it unfolds while also remaining aware of what has gone before. Contextualization means taking into account the response of the particular patient in the situation, including the patient’s history, interrelationships between physiological systems, social interactions with others, and responses to the particular environment. Nurses confront multiple levels of context, from physiology to the family and social world of the patient.
Students come into the clinical setting with assessment skills they have tried to learn in a skills lab. Clinical educators often try to help the students translate these skills from the static lab environment to the dynamic patient care environment by pointing out relevant information and guiding the student to pay attention in order to contextualize their assessment of the patient as they care for them. Some clinical educators weave context into teaching procedures, which may be as simple as giving an injection to a patient:
You teach them to perform a new skill in a nurturing environment, so that no question is stupid; and then to move them from the point of taking the cap off the needle without contaminating it, to being able to identify an injection site, using anatomical landmarks; deliver medication; get that needle back out and dispose of it without sticking yourself. Then the student is guided to look at the response of the patient. So that whole thing of being able to help students to think about not only “Do I need to assess the patient and see why they need a pain med?” [but also] “I have to get the correct pain med and do the six rights of pain medication administration. Then I go and deliver it and then I have to make sure that I follow up and see if it was effective.” And it has to be in the context of the patient. It cannot be in the context of a task alone.
This teacher articulates how good nursing practice always connects skillful performance of a task with the skill of attunement to the patient’s experience and concern. Pedagogies of contextualization include teaching students to avoid overgeneralization from a situation or stereotyping of patients. Instead, they include situated teaching and coaching to help students take into account the patient’s unique history in evaluating signs and symptoms:
We were caring for a diabetic patient who had a low blood sugar that morning and they had done interventions to bring the blood sugar back up. The student got there two hours later. She came to me and said, “He doesn’t look right, he’s kind of pale.” And I said, “Is he sweating?” She said, “Yes,” so I said, “Well, what do you think is going on here? What do you think we ought to do?” We talked through it. If he had low blood sugar two hours ago, and they didn’t recheck it, then maybe it’s still low. And if he’s pale and he’s sweaty, then that means more than likely it is low. And it was low, 47 [normal fasting is 70-99]. So then we had to do some interventions. The thing is that the primary nurse had been in there and didn’t catch it. So it was a learning experience not only for the student but for the staff nurse, who was a fairly new nurse.
Pedagogies of Contextualization
Students must learn to put their patients’ experience into context, including the cultural background, the patient’s environment, illness experience, and relationships with the patient and the family. For example, a clinical educator explained how she uses patient assessment to throw light on the situation a patient is in: “In my view, it’s being aware of the surroundings of a patient, of their behaviors. To me assessment is not necessarily just physical assessment, which we also do. You know, listen[ing] to [their] heart and lungs and doing all of those, but you also assess the client’s interactions. In obstetrics, I assess interactions with their infant, interactions between them and their spouse. I think assessment requires an awareness of the whole surrounding that the client’s in.”
Nurses expect to coach patients and family members on coping and managing their illness or injury. Nurses are taught to consider the patient’s physical environment, the nature of their social and care support, and how patients view their health and illness. Patients recover, but their recovery is not limited to the physiological system. Effective and useful nursing assessment must consider a broader view than a review of physiology. The best nurse’s assessment is contextualized, as this faculty member noted:
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