1. Harvey, Giuliana PhD, RN
  2. Lehman, Jocelyn MSN, RN

Article Content

Clinical experiences provide nursing students with an opportunity to synthesize theoretical and practical knowledge.1,2 Clinical learning experiences take place in multiple patient care settings under the supervision and guidance of a clinical instructor.3 Nursing students are expected to effectively prepare for their clinical practice experiences. Effective preparation consists of providing students with sufficient time to reflect on their assigned patient information, attend to their knowledge gaps, and develop clinical reasoning skills by considering priorities of care.2 To date, few research studies have been conducted to address the topic of nursing students' preparation for clinical experiences.1,4 Despite this lack of research, authors have reinforced the benefit of nursing student preparation as a significant component of learning within the clinical context.1,2 In many schools of nursing, clinical instructors are responsible for selecting and delivering the assigned patient information to students and providing an opportunity for learners to effectively prepare for clinical practice.


Clinical instructors are expected to deliver patient information to students in a manner that strictly adheres to preserving the ethical and legal requirement of patient confidentiality. Standards of practice reinforce the expectation of privacy while working with patient health information.5,6 Variability in the approach used by clinical instructors to deliver patient information to each student generates the potential for violating such standards. In addition, instructors are often challenged with the varying approaches taken by students to understand and apply the information to prepare for the realities of practice. Adopting an approach that both addresses the ethical delivery of patient information from clinical instructors to students and facilitates an opportunity for students to critically think and clinically reason requires serious consideration. To address these considerations, the authors developed and implemented the Clinical Preparation Tool (CPrT), which is provided in Supplemental Digital Content, The development of this tool was underpinned by 2 unfolding concerns: (a) the potential to breach confidentiality and (b) to create an opportunity for students to effectively develop a preliminary patient care plan based on the information provided to them by the clinical instructor. The purpose of this article is to describe the implementation of the CPrT in a Canadian undergraduate nursing program.


Implementation of the CPrT

The implementation of the CPrT was initially piloted by 1 of the authors. The author facilitated learning for a group of 8 third-year nursing students who were completing a 6-week clinical practicum that focused on the acute health care needs of adults. In this course, students were given the opportunity to integrate health-promoting strategies in providing holistic care to acutely ill adults and their families. Concurrent with the clinical course, students were in the classroom learning the theoretical principles that underpinned care of acutely ill adult patients. One of the primary objectives that aligned with the clinical practicum was for students to synthesize and apply the theoretical knowledge from the classroom to practice. Students were expected to create a preliminary nursing care plan for their assigned patient(s) as 1 approach to demonstrating the connection between theory and practice. The CPrT was developed to provide students with an opportunity to enhance this connection.


The CPrT comprised categorical information that was considered common to all patients admitted to the student's assigned unit. Receiving less individualized patient information provided students with an opportunity to consider more broadly the health of the population related to the assigned patient. These categories included postoperative day, admitting diagnosis, procedures, comorbidities, nursing considerations or interventions (eg, chest-tube care, oxygen treatment), scheduled and as-needed medications, diagnostic procedures (eg, laboratory values, x-rays), and other considerations focused on factors that influenced health. Each of these categories was deliberately color coded for ease of use and enhanced clarity. The name, age, gender, room number, and other information considered uncommon or unique that could potentially lead to patient identification were not included in the tool. While age was considered a potential identifier, ranges have been considered for future iterations of the CPrT. Each category contained a checkbox that corresponded to the applicable patient's health information. The final checkbox under each category was noted as "ask me." The "ask me" box was selected when the potential for sharing details from the category was considered a risk of exposing patient information. Students who had the "ask me" box selected had been made aware to seek out the clinical instructor to verbally address the patient's needs in more detail.


Key principles for using this document were located on the reverse side of the single sheet tool. These principles explicitly addressed the rules and expectations that corresponded with the use of the CPrT. The guidelines for using the tool included the following: (1) a pdf version of the tool would be provided by the clinical instructor via email or in person to the students; (2) alterations to the tool could occur at any time; thus, students were expected to review relevant patient information and adjust care accordingly prior to initiating patient information; (3) the tool was to be placed in the appropriate confidential shredding container on the clinical unit at the end of each shift; (4) and the student was to seek the clinical instructor prior to initiating care to obtain further information if the "ask me" box had been checked off.


The author who piloted the CPrT selected the patient assignment for each student. The relevant checkboxes were selected on the tool based on the patient information gathered and then emailed to students so they could begin their preparation. Students used the information from the CPrT to develop their preliminary nursing care plans. The tool required students to address theoretical gaps in their knowledge, anticipate potential priorities of care, and develop a plan for implementing and evaluating these possibilities. The preliminary nursing care plans reflected the potential for this tool to guide the ongoing development of students' critical thinking and clinical reasoning.


One of the initial questions the authors had about the implementation of the CPrT was whether students would have enough information to develop a robust nursing care plan. To address this question, for the first 3 weeks of the course, the author who taught the students reviewed the nursing care plans in advance and offered each student detailed feedback. During the clinical orientation, students were told that they were expected to review each of their assigned patients' charts and to revise the care plan based on the new knowledge they gained from reviewing documentation and in speaking with their patients. The updated changes to patients' plans of care were verbally discussed with the clinical instructor before they proceeded with nursing assessments and interventions. Alterations to each student's nursing care plan became topics of interest in postconference discussions that occurred at the end of the clinical week.


Evaluation of the CPrT

To evaluate the effectiveness of the CPrT, students in 1 session of the clinical course completed an anonymous questionnaire developed by the authors. This survey was not intended to serve as a formal research study, but rather was used to guide the future iterations and use of the CPrT. This feedback reinforced that 75% of the students found the CPrT effective in their preparation for the clinical course. In addition, all of the students indicated the CPrT enhanced their use of critical thinking skills. To further evaluate the CPrT, a quality improvement project was completed in which the tool was piloted with 9 additional clinical groups that completed the same experiential course. Comments from students reinforced benefits associated with the CPrT such as its ease of use and the potential for offering them a broader understanding of the patient and populations with similar characteristics, while preparing for unexpected possibilities. Anecdotally, clinical instructors commented on the simplicity of the tool and their increased confidence in actively protecting patient confidentiality.


Following the initial implementation, the CPrT was modified relative to the context of patient care as well as the knowledge and experience of student groups. To meet the learning needs of second-year nursing students, an addendum was added to the existing CPrT. The addendum contained guided questions under each category for students to consider in their preparation. For example, guided questions that pertained to the heading "admitting diagnosis" included the following: (1) describe the pathophysiology related to the diagnosis and (2) what nursing assessments based on this pathophysiology are the most relevant? The CPrT may be adapted to meet the learning needs of students within different years of the nursing program and for clinical instructors teaching in varying settings such as community placements.




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