1. Logan, Paul CRNP
  2. Clarke, Sean P. PhD, RN, FAAN

Article Content

Clinical experiences are an essential component of any nursing education program. Fifty years ago, hospital diploma programs met the needs of the era by producing graduates with substantial experience in delivering care to patients hospitalized in the "home" institution. Today, that model has changed substantially; most nursing students are formally enrolled in college or university programs and become guests of multiple institutions, including tertiary medical centers, community hospitals, home care agencies, and psychiatric facilities. It's at these institutions that they learn the elements of nursing care.

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In the last Higher Learning column, we focused on setting the stage for excellent capstone experiences at the end of a student's clinical education. Here we offer tips for improving student and staff experiences when students come to your unit during an earlier phase of their clinical development.


Obstacles to overcome

There are many challenges to providing optimal learning for students. It's no secret that, in some regions and specialties, there's a shortage of qualified instructors willing to work for the wages offered. Add to that an abundance of students in prelicensure programs, multiple programs in the same geographic area, shorter patient stays, and fewer clinical sites, and it's apparent that it's difficult to arrange meaningful clinical learning opportunities.


Regardless of senior leadership's commitments to supporting local education programs, there are often large variations in the extent to which nursing education is valued by nurse managers and clinical nurses at the unit level. Working with students may be viewed as an unpaid burden for clinical nurses or a refreshing opportunity to help develop future nurses. Further, nurses and managers on many units may be uncertain of students' ability to safely care for patients.


Placement models

The role of the clinical instructor is to facilitate the student's achievement of learning objectives for each course. The clinical instructor is expected to guide the student in growing his or her knowledge and skill base. However, instructors must also realize that even if they're content experts or employed as clinical nurses outside of their teaching job, the staff assigned to patients are the presumed clinical experts and accountable for processes and outcomes of direct patient care. Even with these clear role distinctions, a number of different arrangements are possible.


In the "drop and run" model, the instructor makes assignments and then leaves the student to provide patient care under the nurse's supervision. This often makes students and nurses uncomfortable, and has the potential to adversely affect learning.


Observation experiences are those in which the student arrives on the unit and the charge nurse assigns him or her to a particular patient, nurse, or room. The student then "jumps in" to provide care when possible, but is often a passive spectator of nursing care. This can be an effective model, particularly when the risks and complexities of total patient care are beyond the student's clinical proficiency. Observation experiences are often popular with students and may not be particularly taxing for the nurse. Nevertheless, such experiences generally don't meet the learning objectives of foundational courses in nursing practice.


Among the approaches valued most by students, nurses, managers, and instructors alike is the capstone, or apprenticeship, model, in which the student is assigned to a nurse preceptor and takes over increasing portions of the preceptor's workload over the course of the placement. However, this model is best suited to end-of-program placements after basic skills are mastered. It should also be noted that instructors sometimes face challenges evaluating student performance consistently and fairly in such an arrangement.


A facilitated clinical placement-the most logical approach for the majority of core clinical experiences-involves an instructor working with a charge nurse to pair the student with patients whose care needs are a good match for the student's skill level. The instructor remains available to the student throughout the clinical day. The facilitated clinical experience addresses several needs: it places the student in a position to achieve course objectives, provides support for the nurse working with the student, and promotes patient safety. Learning how general principles of nursing care translate to a particular work setting is, perhaps, the most valuable and important aspect of the clinical experience. Participating in a clinical experience that has support and structure helps make the student feel confident and allows the instructor to distribute his or her time across the three, four, or more students in the group.


A success story

For some time, medical-surgical students in one program had observation experiences on several ICUs as part of their final clinical course dealing with care of the adult patient with complex health problems. This arrangement took shape in response to a large number of students, a relatively small hospital, and a small number of qualified faculty members, among other reasons. Despite efforts to coordinate all of the observation experiences, communication often broke down.


Charge nurses were sometimes surprised to see students arrive on the floor for their clinical experience. Also, agency nurses were frequently used on these ICUs, which made assignments more challenging. Overall, the results were frustrated nurses who often didn't know what the students were able to do and frustrated students who frequently didn't feel welcome on the units.


The instructors, hospital nursing education staff, and nurse managers gathered to improve the situation. It was apparent that nobody was happy with the current system and everyone wanted to make it better for all involved. The group started with the cardiovascular ICU because cardiology was an area in which involved faculty had a strong background. The students would forgo the observation experience in the cardiovascular ICU and, instead, have a facilitated clinical experience with a clinical instructor on that unit.


The responsibilities of each stakeholder were clearly defined. (See Delineating duties.) To start, the instructor was required to spend an orientation day on the unit. During this orientation, the instructor was introduced to the personnel and workings of the unit, including the unique NP service that manages routine medical issues for all of the patients on the unit. The orientation also gave the head clinical nurses and some of the nursing staff the opportunity to learn about the new method of clinical instruction being trialed.


The nurse manager stipulated that a maximum of five students could be assigned to patients on the unit during a clinical day. The instructor met with the charge nurse at 0615 to determine suitable assignments, taking into consideration student interests and learning needs, course objectives, suitability of staff members to have students, and the appropriateness of individual patients for assignments.


The students were instructed to "get their hands dirty" and take advantage of all that the experience had to offer. They participated fully in all nursing care, including patient assessment, medication administration, nursing procedures, and communication with the interprofessional team. Students weren't required to document in the medical record; rather, they presented their patient during a post conference and wrote and submitted a progress note that was graded by the instructor.


Lessons learned

The response has been enthusiastic on all sides. The students appreciate feeling welcome on the unit and having the opportunity to participate fully in the care of critically ill patients. Both students and nurses are satisfied that the instructor is always accessible to discuss academic questions. And the instructor is happy to have nurses' skills available to the students.


Interestingly, and perhaps coincidentally, there hasn't been a single instance where the nurses or managers have summoned the instructor. In fact, the nurses have been thoroughly engaged with the students and committed to an expanded role in their development. They're very knowledgeable and eager to share their expertise, often going above and beyond what's asked of them. One nurse, for instance, gave a presentation to the students based on an in-service session she had given to staff on intra-aortic balloon pumps.


Although it may sound obvious, open communication between the instructor, students, and nurses was the most important contributor to the success of this program. Other factors that enhanced this experience included clear expectations for all parties and the presence of the instructor on the unit throughout the clinical day. In particular, one recommendation is worth mentioning. Each school has students in multiple and varied settings. Even within one course, students may have clinical days on medical-surgical and CCUs, and observation experiences in the OR. A standard approach for all clinical placements at an institution or within a given specialty benefits everyone.


Nurse managers at many institutions support clinical placements for nursing students on their units. In addition to providing an essential service, clinical placements can also showcase the clinical unit and institution for recruitment purposes. Working together, nurse managers and instructors can design a clinical experience that meets the needs of both students and staff.