Learning Nursing Practice: A Multisite, Multimethod Investigation of Clinical Education

A cognitive task analysis of final year nursing students' situation awareness in simulated deteriorating patient events: A mixed methods study

AIM

The aim of this study was to: (1) use cognitive task analysis to describe final year nursing students situation awareness in recognising, responding and escalating care of deteriorating patients in ward settings; and (2) make recommendations for training and practice.

DESIGN

A mixed methods cognitive task analysis with a convergent triangulation design.

METHOD

Data collection involved observations of 33 final year nursing students in simulated deteriorating patient scenarios and retrospective cognitive interviews. A process tracing technique was applied to identify the cues to deterioration participants perceived; how cue perception altered as situational demands increased; the extent that participants made connections between perceived cues and reached a situational understanding; and the factors that influenced and constrained participants situation awareness. Qualitative and quantitative findings are woven together and presented using descriptive statistics, illustrative quotations and timeline extractions.

RESULTS

The median cue perception was 65.4% and 57.6% in the medical and surgical scenarios, respectively. Perception was negatively influenced by incomplete vital sign monitoring as situations escalated; limited physical assessments; passive scanning behaviours; poor task automaticity; and excessive cognitive demands. Incomplete perception, poor cue integration and underdeveloped mental models influenced situational understanding. Escalation calls did not always accurately reflect situations and a reporting mindset was evident. Clinical exposure to deteriorating patients was described as variable and opportunistic.

REPORTING METHOD

The study is reported in accordance with the Good Reporting of a Mixed Methods Study (GRAMMS) checklist.

PATIENT OR PUBLIC CONTRIBUTION

Patients and public were not involved in this research.

An integrative review of teaching strategies to support clinical judgment development in clinical education for nurses

OBJECTIVES

Historically, emphasis on task-completion and lack of intentional approaches that develop students' thinking skills have dominated clinical education. One contributing factor may be the limited literature about teaching to develop clinical reasoning and clinical judgment in the clinical environment. This integrative review accessed available literature to answer the question, What strategies are used to develop clinical judgment in the clinical education environment?

DESIGN

The Whittemore and Knafl approach framed the integrative review. The framework includes the following steps 1) problem identification, 2) literature search, 3) data evaluation, 4) data analysis, and 5) presentation.

DATASOURCES

The data bases CINAHL Plus with Full Text, OVID, and ProQuest were searched through the period of January 2000 through July of 2022.

REVIEW METHODS

The PRISMA protocol informed review and screening of the literature. Authors assessed articles for eligibility via first screening by abstract review, followed by review of the full text. Both authors reviewed the articles, assessing qualification for inclusion and evaluating the content. Data from eligible articles were analyzed and synthesized to answer the research question.

RESULTS

Of the initial 427 articles, a total of 20 articles met inclusion criteria for final analysis. Five general themes emerged for clinical judgment during clinical education. The findings identified the teaching strategies nurse educators use. Many of the teaching methods include deliberateness and intentionality in planning and implementing the strategies. In addition to evaluating clinical judgment, nurse educators guided and mentored student thinking. Finally, this review identified reported outcomes and results of the teaching strategies and methods.

CONCLUSIONS

A limited number of articles describing teaching for clinical judgment in clinical environment were found. The articles analyzed found that nurse educators used a variety of teaching strategies for the purpose of developing students' clinical judgment. More research is needed to guide best-practices in clinical education. We must move the science forward to transform and leverage clinical education more deliberately to teach thinking in practice and decision-making about patient care.

Development and Assessment of Professional Competences among Polish Nursing Students during a 3-Year Education Cycle Trying

The essence of the profile of nursing professional competences are basic behavioral characteristics, as well as mastering practical skills. The aim of this study was determination of the development of professional competences of perceiving a patient by first-, second-and third-year students of licentiate nursing study. The study was of a longitudinal character, and lasted for 3 years. The research instrument used was the Ascent to Competence Scale, and traditional assessment of students’ knowledge and skills. A statistically significant relationship was observed between the average grade in practical education from all three years, and competences in student–teacher relationship. Higher grades in theoretical education were accompanied by lower results obtained by students in the area of nursing competences. The respondents’ opinions concerning the development of knowledge and professional skills were relatively high among first-year students, which may be related with a sharp increase in nursing knowledge, whereas third-year students considered it important to perceive a considerable development of professional competences. The results of this study can help in the design of education programs meeting quality standards, and alignment with students and population health needs, which is adequate to the assumptions of the WHO Global Strategic Directions for Nursing and Midwifery 2021–2025.

A phenomenographic study exploring the conceptions of stakeholders on their teaching and learning roles in nursing education

BACKGROUND

Nursing education involves a number of stakeholders in the teaching and learning process, and these are student nurses, lecturers, clinical instructors and nurses. The role that each of these parties play in the teaching and learning process is dependent on each other and is key to the development of competence among student nurses. However, there is scanty literature on the discourse of how these stakeholders conceptualise their roles to maximise student learning. The objective of this study was to explore the conceptions of stakeholders on their teaching and learning roles in nursing education.

METHODS

Thirty-eight semi-structured interviews and three focus group discussions were conducted with nursing students, lecturers, clinical educators at a Namibian nursing college and nurses at teaching hospitals. Phenomenographic data analysis approach was applied.

RESULTS

Four conceptions were constructed that described the level of involvement of the different parties in teaching and learning. These were initiating, supporting, becoming part of and owning the teaching and learning role. Three dimensions of variation marked the differences among the conceptions: responsibility and accountability, priorities and level of collaboration.

CONCLUSIONS

The parties involved in the teaching and learning in nursing education have qualitatively different understating of their roles and those of others. There is a pattern transcending from being at the periphery of teaching and learning to taking ownership of teaching and learning. And a movement from limited responsibility and collaboration to that of being responsible, accountable and high level of collaboration in the teaching and learning of nursing students. The conceptions in this study add more ways of enhancing collaboration between theoretical and clinical sites in nursing education, by ensuring that those involved are aware of their role and that of others and work collaboratively at the micro-level.

Developing Students' Clinical Reasoning Skills: A Faculty Guide

BACKGROUND

Safe patient care relies on the ability of nurses to make timely, sound clinical judgments, yet new nurse graduates are underprepared. Nurse educators must take action with teaching to develop students' clinical reasoning skills and ultimately their clinical judgment. One first step is to consider strategies that integrate clinical judgment and clinical reasoning skills into nursing curriculum.

METHOD

The literature was reviewed to uncover what is known about teaching strategies that intentionally teach clinical reasoning skills and are focused on the development of students' clinical judgment.

RESULTS

Although not exhaustive, this guide for faculty discusses first steps when considering integrating clinical reasoning and judgment into nursing curriculum, presents teaching strategies, and provides ideas for implementation within nursing curriculum.

CONCLUSION

Teaching clinical reasoning skills, using a framework, and incorporating teaching strategies such as concept-learning, high-order questioning, and reflection focused on developing clinical reasoning skills may prove useful in developing students' clinical judgment. [J Nurs Educ. 2021;60(9):485-493.].

Script Concordance and the Think-Aloud Approach Through the Lens of Cognitive Apprenticeship Theory

BACKGROUND

Script concordance (SC) and the think-aloud (TA) approach informed by cognitive apprenticeship theory can promote clinical reasoning.

PURPOSE

The purpose of this study was to determine whether SC with the TA approach based on the tenets of cognitive apprenticeship theory facilitated clinical reasoning in senior-level prelicensure nursing students in a baccalaureate program.

METHODS

This study was executed in a didactic pediatric nursing course using a quantitative, nonexperimental design. Creation of the SC/TA learning activity was grounded in cognitive apprenticeship theory and based on the SC testing/TA testing method.

RESULTS

Repeated-measures analysis of variance revealed a difference (P = .001 and .003) between earlier and later SC scores for the fall 2018 cohort.

CONCLUSION

The SC/TA teaching/learning activity informed by cognitive apprenticeship theory offers a leveled approach to foster clinical reasoning in prelicensure nursing education.

Professional Development for Simulation Education

Professional development in simulation methodologies is essential for implementation of quality, consistent, simulation-based experiences. Evidence demonstrates that participation in comprehensive training positively impacts learner outcomes. There are many benefits to professional development, however, challenges exist requiring thoughtful planning, administrative buy-in, and fiscal support. While there are no established guidelines, the literature provides an ongoing consensus related to overall concepts and strategies for training in simulation. We describe a continuum of growth for simulationists, ranging from novice/advanced beginner, competent/proficient, to expert. As a novice, one must conduct a self-assessment of current strengths and create a development plan to advance simulation skills and knowledge. A simulationist should use evidenced-base guidelines, mentorship, and feedback to inform simulation practices. They should be knowledgeable of the standards of best practice, modalities, simulation design, learning theories, and professional integrity. Simulationists must seek ongoing advancement through certification, scholarship, and lifelong learning. This chapter describes the continuum of education and methodologies for the development of simulationists.

WARRIORS: An Educational Initiative Improving Clinical Judgment and Safety in Medication Administration

BACKGROUND

Medication administration requires rigorous clinical reasoning leading to sound clinical judgment for positive patient outcomes. The National Council of State Boards of Nursing is implementing a clinical judgment model for the licensure examination.

METHOD

To support the practice of clinical judgment in administering medication, improve patient safety, and better prepare nursing students for their licensure examination, a clinical reasoning initiative was developed to reflect the judgment needed for safe medication administration. An acronym, WARRIORS, captures the decision process exemplifying the knowledge, skills, and attitudes needed to keep patients safe.

RESULTS

A free training tool (https://www.youtube.com/watch?v=YkBeGymEMuQ) and an online electronic health record (http://www.nursing.pitt.edu/aliceblazeckrn/) guiding deliberate practice provide interrelated cues to support nursing students in forming a hypothesis through taking action and evaluation.

CONCLUSION

This learning initiative supports nursing students' safe and accurate medication administration and can continue to be used as they move into practice. [J Nurs Educ. 2020;59(4):231-234.].

Using the Two-Minute Assessment With Debriefing to Optimize Traditional Patient Care Clinical Experiences

Traditional patient care clinical experiences present numerous challenges to faculty in prelicensure nursing education. This article presents an adapted nontraditional clinical activity for use in patient care clinical experiences. The Two-Minute Assessment With Debriefing incorporates peer collaboration and attributes of debriefing, including assimilation, accommodation, and anticipation. Nursing students in acute care facilities are assigned to either traditional or nontraditional care, with the group ideally split in half. The use of nontraditional clinical activities with reflection has been supported as a strategy to engage higher order thinking about patient care while allowing focused faculty time with students in traditional patient care.

Evaluation of a Wellness Clinic in Assessing Knowledge Synthesis Among Bachelor of Science in Nursing Students

BACKGROUND

To enrich students' clinical learning experience and facilitate their ability to meet the baccalaureate outcomes, students rotate through a faculty-developed nursing wellness clinic. This unique setting was thought to promote knowledge synthesis of the Bachelor of Science in Nursing (BSN) curriculum, yet it had not been formally evaluated.

METHOD

A qualitative study was designed to examine the experiences of senior BSN students who rotated through the wellness clinic setting. Focus groups were held for students who volunteered to participate.

RESULTS

Analysis identified three themes: Competence and Confidence Issues, Rewards and Frustrations of Delivering Care in the Community, and Using What We Know.

CONCLUSION

Findings indicate that nursing wellness clinics can provide a rich learning experience and enable students to synthesize the BSN and liberal arts curriculum in order to deliver care. The study is limited due to the small sample size. Future research on the effectiveness of this clinical placement is warranted. [J Nurs Educ. 2020; 59(1):26-29.].

Teaching Clinical Reasoning Piece by Piece: A Clinical Reasoning Concept-Based Learning Method

BACKGROUND

Recent discourse generates a more thorough understanding of what clinical reasoning entails. Although numerous strategies prioritize clinical reasoning development, teaching and evaluating the thinking involved in clinical reasoning remains a struggle for nurse educators, particularly regarding clinical education.

METHOD

In response, the author developed a concept-based clinical reasoning teaching method with weekly themes, lessons, and learning activities adapted from Tanner's clinical judgment model and Lasater's Clinical Judgment Rubric.

RESULTS

The method offers an organized, consistent approach to teaching and learning clinical reasoning, with multiple opportunities for student reflection, instructor guidance, and discussing clinical reasoning concepts. Clinical education became transformed for both the nurse educator and nursing students as clinical reasoning became a visible part of students' budding nursing practice.

CONCLUSION

Nurse faculty must ensure future nurses are prepared to think-inaction. The clinical reasoning teaching method offers one potential solution. [J Nurs Educ. 2018;57(12):727-735.].

Pursuing Improvement in Clinical Reasoning: Development of the Clinical Coaching Interactions Inventory

BACKGROUND

Clinical coaching has been identified as a signature pedagogy in nursing education. Recent findings indicate that clinical coaching interactions in the clinical learning environment fail to engage students in the higher order thinking skills believed to promote clinical reasoning.

METHOD

The Clinical Coaching Interactions Inventory (CCII) was based on evidence of supervisor questioning techniques, the Tanner clinical judgment model, Bloom's Taxonomy, and simulation evaluation tools. Content validity was established with expert assessment, student testing for clarity, and calculation of scale-content validity index/average (S-CVI/Ave). Reliability was established with Kuder-Richardson Formula 20 (KR-20).

RESULTS

CVI (S-CVI/Ave) was .91, and KR-20 was .70. The CCII identified differences in clinical coaching behaviors in university faculty supervisors and staff nurse preceptor supervisors.

CONCLUSION

The CCII advances the measurement of clinical coaching interactions from qualitative to quantitative. Ultimately, results from use of this inventory may facilitate the design of prelicensure clinical coaching strategies that promote the improvement of students' clinical reasoning skill. [J Nurs Educ. 2016;55(9):495-504.].