Practice learning 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 (Childs, 2002).

Simulation

According to Rush, Dyches, Waldrop, and Davis (2008), “Simulation is a strategy increasingly being used to promote critical thinking skills among baccalaureate nursing (BSN) students.” Schiavenato (2009) also states, “The human patient simulator or high-fidelity mannequin has become synonymous with the word simulation in nursing education” (p. 388). Bremner, Aduddell, Bennett, and VanGeest (2006) believe that the incorporation of high-fidelity mannequin technology is one of the most important issues in nursing education today. Simulation may assist in supplementing didactic content in the classroom or it may be used to ensure that all students in a clinical course would experience a patient situation that may not be available during the regular clinical day. Schools across the country are increasingly using human patient simulators for teaching a part of a student’s clinical nursing course. When evaluating the effectiveness of this teaching strategy, those involved need to determine what was learned and gained in the experience and what knowledge will be transferred to the real clinical setting, which will ultimately affect patient care. There are variations among Boards of Nursing as to the use of simulation in the curriculum. (See Chapter 20 for further discussion of simulations.)

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 such as Second Life that can create virtual clinical environments (Schmidt & Stewart, 2009) and use existing technologies such as e-ICUs and telehealth capabilities to create opportunities for additional clinical experiences. According to Grady (2006), “Nursing education practices have changed little in response to massive and sweeping changes in the complex and dynamic health care environment” (p. 125). Research has been conducted to better define and “test leading-edge telehealth methods and technologies that can extend the reach of nursing in clinical areas as well as classroom settings” (p. 124). The Virtual Clinical Practicum (VCP) was 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. The students can interact with the nurse and patient using telehealth technology. The VCP process was developed as a potential solution to expanding nursing school enrollment to accommodate the nursing shortage in the face of limited clinical practice sites as well as limited clinical experts, 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 more complex. The complexity relates to factors such as extensive use of technology (e.g., electronic record keeping), rapid patient and staff turnover, high patient acuity, and complex patient needs. Because of this complexity, there are increased safety risks for students, patients, faculty, and staff. Therefore safety must be enhanced through the use of creative teaching and learning strategies to ensure safe practice and the development of the student’s ability to think critically while acquiring the competencies that facilitate attainment of curriculum outcomes. Examples of these strategies include assignment methodologies such as multiple assignments and teaching modalities (e.g., nursing grand rounds); simulated clinical scenarios; case studies; computer-assisted instruction; and the use of interactive CD-ROMs, shadow experiences, and virtual simulations (VCP, e-hospitals). Guided and focused small group sessions and selective capstone experiences also may facilitate students’ acquisition of needed knowledge and skills.

The complexity of the environment also provides opportunities for faculty to become facilitators of learning, designers of clinical experiences, and developers of flexible skill sets that can be used across settings. Faculty must provide experiences to help students think, care, and act like nurses—and finally to be nurses (Tanner, 2002). For this to occur, the outcomes for specific learning experiences must be clearly identified and articulated.

Every health care environment and specific unit within these environments has a culture. The culture of the immediate environment affects teaching and learning. For example, the culture—or patterns of actions and behaviors—of the health care professionals can be observed in their attitudes, interactions, sense of support for each other, and commitment to quality patient care. These actions and behaviors can be influenced by staffing levels, acuity of patients, anxiety of staff, and workload. These aspects of the culture of the environment can in turn influence the time staff have 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.

Community-based environments

The health care delivery system is continuing to shift from acute care hospital environments to the community. Several factors have facilitated this shift, including social, technological, and economic changes as well as the politics of health care. These changes have resulted in an increased use of community agencies such as ambulatory, long-term, home health, and nurse-managed clinics; homeless shelters; social agencies (e.g., homes for battered women); physicians’ offices; health maintenance organizations; worksite venues (Schim & Scher, 2002), art galleries; day care centers; and schools (Buttriss, Kuiper, & Newbold, 1995; Chan, 2002; Faller, McDowell, & Jackson, 1995). Summer camps are also being used for special experiences (Totten & Fonnesbeck, 2002). Depending on the purpose of the camps, multiple objectives can be accomplished. For example, camps for children with health issues can be used for acquisition of targeted skills that could be obtained in acute care settings. Camps for healthy children could be used for acquisition of knowledge and skills relating to normal growth and development and communication.

The use of technology such as video conferencing, wireless remote communication, information systems, and online courses has made it possible for clinical experience to occur at a distance. The transition to community-based teaching requires faculty to adapt practicum skills to new technology, modify teaching methods, and adapt to methods of clinical supervision such as being accessible by pager or texting device.

Establishing appropriate and sufficient learning experiences in the community may be difficult and challenging. These challenges often relate to economic constraints and the nursing shortage, 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.

Selecting health care environments

Regardless of the practice environment, faculty are responsible for selecting appropriate health care agencies and being 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 accreditation status, adequacy of staff, the patient population for needed experiences, and expected course outcomes, whether or not the practice model is compatible for intended uses and curriculum needs. In addition, the adequacy 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 due to 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 in turn creates opportunities for faculty to be creative in the manner in which learning experiences are selected and teaching strategies are used. Regardless of the limitation, the role of the faculty is to assist students in making learning connections.

Despite all efforts on the part of classroom and clinical faculty, there seem to be times of “great divide” between the two arenas. Benner, Sutphen, Leonard, and Day (2010) indicate that “even with faculty commitment to integration, all too often, nursing education is approached as if it has two discrete elements” (p. 159). Dual clinical and classroom assignments for faculty will 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.

Building relationships with personnel within health care agency environments

According to Piscopo (1994), “roles identify relationships and are interactional and reciprocal” (p. 113). 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 (Lee, Krystyna, & Williams, 2002). This requires having an understanding of the environment and the roles of the individuals within the environment, and a realization that these 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 the staff’s ability 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.

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 facilitates the measurement of student performance. The manner in which the curriculum is organized facilitates the planning of learning experiences in a logical, rational sequence. The curriculum is designed to build on prior knowledge and to reinforce 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 positive learning. 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 experiences, 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 males. 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 opportunities; 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 clinical learning environment as “the interaction network of forces within the clinical setting that influences student learning outcomes” (p. 70). A number of forces affect expected outcomes, including the increased complexity of care required by patients with higher acuity, the nursing shortage, the rapid pace, and multiple health care professionals and activities. 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. Clinical strategies can be developed to reduce anxiety in clinical environments, especially where anxiety levels are high. Some strategies focus on the level of students. Two such strategies are (1) peer coaching, in which senior students coach beginning students (Broscious & Sanders, 2001), and (2) placement of students in long-term care settings.

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 for integration of theory, application of critical thinking and clinical reasoning, or effective evaluation of the interventions performed. Faculty know that the clinical environment is not always conducive to student learning. Nursing staff are overworked, stretched thin due to consistently working in a short-staffed environment and caring for patients that are critically ill with multiple health care needs. Nurses intuitively want to be good role models and nurture students but often do not have the time to do so.

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 that 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.

Faculty are responsible for accessing information systems such as websites, tutorials, structured meetings management, or orientation sessions within affiliating agencies and for shadowing staff in the immediate care area. The use of either of these techniques informs and facilitates decision making. Information should be reciprocal so that all parties (faculty, students, and staff) can learn.

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. 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.

Practicum experiences are selected and planned to provide students with opportunities to work across settings and manage care for varied populations with an emphasis on prevention and primary care. 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 interdisciplinary teams and in practice environments when interdisciplinary practice models are used for joint planning, implementation, and evaluation of outcomes of care. The goal of interdisciplinary education is to foster interprofessional relationships while enhancing contribution to each discipline.

Learning to collaborate with the many health care groups involved in patient care can be a daunting task. It is believed that the use of interdisciplinary 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. Rodehorst, Wilhelm, and Jensen (2005) indicated that the use of interdisciplinary learning helps to clarify the roles of each discipline and enhances learning from one another.

Nursing faculty are increasingly participating in teams and designing interdisciplinary clinical courses and learning experiences. Successful course development and implementation depend on faculty’s commitment to the goal of interdisciplinary 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 interdisciplinary education is increased future collaboration among professionals. 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 interdisciplinary 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.

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 accomplish specific objectives and to achieve specific competencies and individual learning needs are appropriate (Gubrud-Howe & Schoessler, 2008). If that is the goal, faculty would plan for a focused clinical experience. Specifically, students may interview patients to work on communication skills, perform vital sign assessments to develop this particular skill set, observe in a specialty area, and give and receive reports. The focus of each experience is some needed skill set for students’ or an individual’s learning needs.

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 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 that are selected and the practice opportunities that are provided for students should be congruent with the program outcomes.

Evaluating experiences

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 27.

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. Porter and Feller (1979) examined the achievement of baccalaureate nursing students who either had clinical experience in two alternating clinical sites over a 16-week period or had experiences at one site for 8 weeks, followed by experiences at a second site for the last 8 weeks. No differences in scores on National League for Nursing Achievement Tests were found. Similarly, Dunn, Stockhausen, Thornton, and Barnard (1995) reported that no differences in clinical learning outcomes occurred when clinical assignments occurred either 1 or 2 days per week or in alternating 2-week blocks of time. Often students reported being frustrated by nonsequential clinical experiences because of the inability to form relationships with nursing staff and mentioned that they might provide an intervention in the morning but never are at clinical long enough to evaluate the effectiveness of that intervention. Schools are now rethinking the length of the clinical day and the need to experience a typical nurse’s daily schedule.

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. Some acute care hospitals have a 12-hour shift option while 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.

While 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. According to Miller (2005), it is critical that students have adequate time on any given unit to progress beyond the minimum and to be exposed to the unit’s structure, operations, and culture. Additionally, students described positive aspects of the clinical experience as having an experience at a particular organization, the clinical experiences, and the timing of assignments on work and family responsibilities (Dunn et al., 1995).

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 can also be 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 mesh schedules of students from more than one school of nursing. Thus ideal scheduling may not be a reality.