[LiveToLearn]

I am a nurse educator and would like your opinions on clinical experiences. Other than things that should always occur (but don't always!) such as encouragement and demonstration of respect for patients and students, what are your suggestions for making clinical experiences very helpful? I am particularly interested in the following areas:

1. what has been the most helpful format for pre- and post conferences?
2. what learning strategies have most helped you in the clinical setting?
3. what actions on the part of the instructor most contributed to your learning?
4. what can instructors do to make clinical and coursework more relevant to actual practice and not just "busy work"?
5. I have done away with numerous and lengthy care plans in favor of tools such as giving/receiving report to other students, oral care plans, grand rounds (students present a case and discuss the case with the instructor and other students), and giving second semester students the opportunity to perform a brief assessment and then plan their care with books in the conference room. What alternatives to care plans have you found helpful?
6. is there any other information you would like to provide to improve clinical education?

Thank you for your time.

[chevyv]

First I would like to take a moment to thank you for getting rid of the lengthy care plans. I understand why most require them, but I've had so many nurses tell me that when you actually start your job, you just print out a generic type that is most often used. I can't really tell you that I learn a whole lot from doing them. Usually, I have one to do each week and it just takes over everything, so that I find my life revolving around it. It's been almost a month since 3rd semester ended and I can't tell you about them at all.
I like my clinical instructor to be there when I need her for procedures. I'm the type who asks if I'm not 100% sure (or I look it up if time permits). Once I'm comfortable, I need my instructor to step back and let me develop the confidence. Don't hover over my every move unless its warranted. You won't be there after graduation anyhow.
The one thing that I've heard new nurses say is that they wish they could have been 'taught' how to phone the doc when needed. I had really never thought about that before, but they do have a point. Learning how to deal with docs on the phone should be at least touched on. I would like one of my instructors to teach me what to expect and what info to collect before placing my call. I hope this helps a bit

[LiveToLearn]

Thank you! Calling the physician is such a daily part of life it seems. This is a great idea. It would give them the chance to practice. When I precept people in the ICU, I always had them pick up another line and listen in as I made calls and also gather information they thought was relevent prior to the call, so they would be used to what was asked in a typical conversation. This would be a great tool for students, I will incorporate that. Thanks!

[Freedom42]

Thanks for asking these questions. I just completed a three-month rotation that was fraught with frustratino because the instructor, an excellent nurse, did not know how to teach. Here's what I wish I could have said to her:

1. what has been the most helpful format for pre- and post conferences?

How I wish you'd had them! By the time you arrived on most days, I'd been on the floor for 30 to 45 minutes. It would have been great to start the day, with, say, a few minutes of discussion over what was expected of students when working with nurses and aides. None of us ever knew, and when we asked for you specifics, they changed constantly. The nurses were as frustrated as we were. The morning would also be a great time to review those things we studied four months earlier but haven't looked at since, like how to program an IV pump. At the end of the day, I would have appreciated your telling us what you observed on the floor that day, good and bad, and what we need to work on or review. Or how about having someone come in to talk about his or her role at the hospital, like a dietitian or an RT? I'd like to get to know how to work with other members of the health care team.

2. what strategies have most helped you in the clinical setting?

Obviously what a student can learn at each clinical is subject to the patients and what's happening on the floor. But it would have been helpful if we had had specific goals; i.e., everyone learns how to put in a Foley by week 8, everyone learns how to give IV meds, and by the end of the semester, everyone knows how to do X, Y and Z. We had no goals. We were thrown onto the floor and expected to give meds from the get-go. Nothing was clear. It was very frustrating. Tell us where we're going and how to get there -- then let us find our way!

3. what actions on the part of the instructor most contributed to your learning?

Because my instructor did so little, I had to get a lot of education from the nurses and aides. What a generous group! I scheduled shadow time with a senior nurse during my spring break -- the experience was invaluable. I came in early for every clinical and stayed late. Though I could not get meds unless my instructor was on the floor, I learned a lot from watching and helping.

4. what can instructors do to make clinical and coursework more relevant to actual practice and not just "busy work"?

Please don't make me write a "journal" entry every week about my "feelings." Trust me: After the first week, I made it all up. I don't have time for that nonsense when I'm researching 30 drugs the night before clinical, making drug cards and putting together a 30-page care plan every week. If you want me to write about something, make it something I'm dealing with on the floor (like the lengthy paper I wrote on negative-pressure wound vacs that was never even acknowledged, not that I'm bitter! ). I attended roungs with my nurse and presented when called upon (did I mention those nurses were great?). Personally, I did find care plans helpful -- but I love researching pathophys. And I also found conversations with classmates about their patients to be great learning opportunities.

Thanks again for asking. This has been most therapeutic...

[ADNOLOL08]

First off, I think it's a great idea that you're so interested in providing great clinical experiences for your students.

1. what has been the most helpful format for pre- and post conferences?

The best format for pre-conference was a brief discussion of our patients, the medications they were on, treatments scheduled, discussion of diagnosis. Sometimes, a student or two would be away from clinical due to other clinical work at a different facility. If this occured, then they would have to research a topic (i.e. cellulitis) and give a report on it. A great learning experience, I thought. We didn't have this, but I think it would have helped. If the students aren’t scheduled to begin clinicals until after report, the instructor gathering report and speaking to students about their patients is helpful. There were times when our clinical was scheduled after shift change and we had to search for the nurses to get report. This was a nuisance for both students and nurses as it took away from patient time.

As for post-conference, discussion of our day and any questions we had about care were posed.

1. what learning strategies have most helped you in the clinical setting?

Discussion about patients, patient scenarios, and hands-on skills.

1. what actions on the part of the instructor most contributed to your learning?

Discussion of medications, diagnosis (why such and such symptoms are occuring, etc) and accompanying students in the room for procedures (first few times) Please do not do something for the student, even if you may be in a hurry, and please don't just stare blankly at the student while they're doing a procedure

1. what can instructors do to make clinical and coursework more relevant to actual practice and not just "busy work"?

Use of patient scenarios. I loved the case studies that we did in class. You can either give multiple choice answers to questions that you would ask, or simply let the students think of answers themselves (especially the last two semesters). I found both formats worked well in promoting critical thinking and knowledge retention.

1. I have done away with numerous and lengthy care plans in favor of tools such as giving/receiving report to other students, oral care plans, grand rounds (students present a case and discuss the case with the instructor and other students), and giving second semester students the opportunity to perform a brief assessment and then plan their care with books in the conference room. What alternatives to care plans have you found helpful?

I think that these ideas are wonderful, especially practicing report. The care plans became rather redundant after second semester. As for alternatives...I haven't personally come across any that work.

1. is there any other information you would like to provide to improve clinical education?

I agree with the practice of phoning the doctor/pharmacy/etc. This is one area where I am feeling very anxious in. And though we didn't have this, I think that having short term goals set for each clinicial week would give students something to work with. Figure out what sort of procedures your students haven't had the opportunity to do, and if the situation arises, then get that student. Rotations to other hospital departments are helpful.

[locolorenzo22]

First, let me say that as a future nurse educator myself, I am pleased that you would actively seek out student(and former student) input in order to help plan out clinicals. It sometimes seemed that instructors were just "winging" it each day, and made for a LONG 8 hrs.
1.what has been the most helpful format for pre- and post conferences?
Personally, I felt that pre-conference was MOST helpful when we could go around in a group and discuss(briefly) who we were taking care of and what they had....i.e. "I'm taking care of RM in 232, who has end stage renal disease..I'm going to find out if he's going on dialysis today, and what his BUN/creatine is today, etc." also, if there was any opportunity to get skills signed off on our skills card, (i.e. flushing or giving medication through a PICC line) and we had it done, we were able to have another student do that with the instructor...
Post-conf was helpful when we discussed what we had done during the day, or what being a "real-life" nurse could have done differently from us in the "student" role...or even just to vent about the staff nurse in a forum free from judgement...within professional reason, of course.

2. what learning strategies have most helped you in the clinical setting?
Hands-on doing and talking before doing were always the most helpful....

3.what actions on the part of the instructor most contributed to your learning?
Allowing me to talk out a plan of action and allowing me to perform care and trusting that, once I have proven myself safe, I will come get you if there is a problem...however, please, feel free to come ask me what is going on with my patients...so I can prove myself to you....

4. what can instructors do to make clinical and coursework more relevant to actual practice and not just "busy work"?
I think that databases and finding info is important for organzing care at first...but as it becomes more advanced perhaps more "hands-on" viewing or participating in different procedures would help....I only did 1 thoracentisis in school, and that was during my preceptorship at the end of 2 years for 36 hrs....

5I have done away with numerous and lengthy care plans in favor of tools such as giving/receiving report to other students, oral care plans, grand rounds (students present a case and discuss the case with the instructor and other students), and giving second semester students the opportunity to perform a brief assessment and then plan their care with books in the conference room. What alternatives to care plans have you found helpful?
I honestly think you've figured it out...Also, are there opportunities for students to be "charge" or be responsible for other students, to provide a management chance? We were asked to supervise 2 other students, be responsible for their care(all assessments charted, required nursing note 1 per shift done, all medications passed, glucoscans done, insulin given, report given to charge student then to staff nurses...etc.) It was a good learning exp. to learn how to manage others....even those students who were not quite that good...

good luck with improving clinicals....they get a bad rap...

[LiveToLearn]

Thanks everyone for the great advice. I always ask my students for feedback halfway through the semester and at the end of the semester. I've found each group to be different and to need different teaching styles. I teach first, second, and third semester students. First semester, I am trying to help them with basic assessment and just noticing what is happening with their patient. By second semester, the focus shifts more to ensuring they see the connection between the disease process, the assessment, and interentions. We continue this in third semester, adding in progressively more collaborative care. I am so proud of all of them, it is so exciting to see a student move from terrified and unsure to skilled and confident! It never gets old.

I have done this in the past with second semester students at the beginning of the semester:
I bring them to the floor the first day, and they are assigned a patient. I then ask them to go to the floor, listen to report, get a print-out of the patient's meds, and perform a 10 minute assessment. They then return to the conference room. Each student is assigned to bring one of the texts to clinicals (ex- peds, pharm, pathophys) so each student isn't loaded down with texts.

Then they present their case (briefly), and work in groups to look up meds, relevant assessments, and plan care within the next 30 minutes. They will then present (briefly) their priorities of care for the day and return to the floor. It takes about an hour. I then go to the floors and make rounds to ensure they understand the patient's care, procedures, etc and feel confident. This pretty much takes up the rest of my day as I spend at least an hour with each student, practicing assessment and delivery of care. Needless to say, I spend a bit less time with third year students and am more available but "in the background" so I am there if they need me.

At the end of the day, postconference is spent either discussing what care took place and if the plan needs a change, or having special speakers in to talk about their role, or focusing on a specific topic (ex- oxygenation/ventilation). I do have the 2nd semester students perform at least one written care plan. If they are successful, the others may be delivered in oral report.

They are still doing so well, and I always thought that a care plan shows what you *could* do and not necessarily what you would or will do. I think sometimes that students spend so much time (8 hours or more in some cases) writing a care plan, that they end up with no time to actually care for the patient and learn. And as many of you well know, you end up sleep deprived! I don't think it is ok to tell someone to live a balanced life, then assign them 8+ hours of work to perform after the clinical day is over. We don't do this in the real world, you have to think "on the fly".....so my goal is to teach them to do this when I am no longer there to support them. So far they've done very well!

Any more ideas? I am always open to consider them. Students are the future of nursing, anything we can due to ensure their success is an investment that will pay off.