Evaluation of Clinical Outcomes and Competencies In Nursing Education
Whats Is Feedback in Clinical Evaluation
For clinical evaluation to be effective, the teacher should provide continuous feedback to students about their performance and how they can improve it. Feedback is the communication of information to students, based on the teacher's assessment, that enables students to reflect on their performance, identify continued learning needs, and decide how to meet them (Bonnel, 2008). Feedback may be verbal, by describing observations of performance and explaining what to do differently, or visual, by demonstrating correct performance.
Feedback should be specific and accompanied by further instruction from the teacher or by working with students to identify appropriate learning activities. The ultimate goal is for students to progress to a point at which they can judge their own performance, identify resources for their learning, and use those resources to further develop competencies.
Bonnel (2008) emphasized that for feedback to be useful, students need to reflect on the information communicated to them and take an active role in incorporating that feedback in their own learning (p. 290).
Students must have an underlying knowledge base and beginning skills to judge their own performance. Brookhart and Nitko (2019) suggested that feedback on performance also identifies the possible causes or reasons why the student has not more tered the learning outcomes. Sometimes, the reason is that the student does not have the prerequisite knowledge and skills for developing the new competencies.
As such
it is critical for clinical teachers and preceptors to begin their interactions
with students by assessing whether students have learned the necessary concepts
and skills and, if not, to start there.
The Principles of Providing Feedback as Part of Clinical Evaluation
There are five principles for providing feedback to students as part of the clinical evaluation process. First, the feedback should be precise and specific. General information about performance, such as “You need to work on your assessment” or “You need more practice in the simulation center,” does not indicate which behaviors need improvement or how to develop them. Instead of using general statements, the teacher should indicate what specific areas of knowledge are lacking, where there are problems in thinking and clinical judgments, and what particular competencies need more development.
Rather than saying to a student, “You need to work on your assessment,” the feedback would be more effective if the teacher identified the specific areas of data collection omitted and the physical examination techniques that need improvement. Specific feedback is more valuable to learners than a general description of their behavior. Second, for procedures, use of technologies, and psycho-motor skills, the teacher should provide both verbal and visual feedback to students.
This means that the teacher should explain first where the errors were made in performance and then demonstrate the correct procedure or skill. Research suggests that physically guiding learners in how to perform the procedure or skill improves their accuracy (Soderstrom & Bjork, 2015). This should be followed by the student practicing the skill with the teacher guiding performance. By allowing immediate practice, with the teacher available to correct problems, students can more easily use the feedback to further develop their skills.
Third, feedback about performance should be given to students at the time of learning or immediately following it. Giving prompt feedback is one of the seven core principles for effective teaching in undergraduate programs (Chickering & Gamson, 1987). Providing prompt and rich feedback is equally important when teaching graduate students, nurses, and other learners regardless of their educational level. The longer the period of time between performance and feedback from the teacher, the less effective the feedback (Oermann et al., 2018).
As time passes, neither student nor teacher may remember specific areas of clinical practice to be improved. This principle holds true whether the performance relates to clinical judgment or other cognitive skills, a procedure or technical skill, or an attitude or value expressed by the student, among other areas. Whether working with a group of students in a clinical setting, communicating with preceptors about students, or teaching an online course, the teacher needs to develop a strategy for giving focused and prompt feedback to students and following up with further discussion as needed.
Recording short notes for later discussion with individual students may help the teacher remember important points about performance. Fourth, students need different amounts of feedback and positive reinforcement. In beginning practice and with clinical situations that are new to learners, most students will need frequent and extensive feedback. As students progress through the program and become more competent, they should be able to assess their own performance and identify personal learning needs. Some students will require more feedback and direction from the teacher than others.
As with many aspects of education, one approach does not fit all students. Feedback should always be given to students in a private area. One final principle is that feedback should be diagnostic. This means that after identifying areas in which further learning is needed, the teacher's responsibility is to guide students so that they can improve their performance.
Altmiller (2016) emphasized the importance of being
attentive to how the feedback is delivered: the teacher should identify the
feedback as an opportunity for student learning and include options for
improvement. The process is cyclical the teacher observes and assesses
performance, gives students feedback about that performance, and then guides
their learning and practice so they can become more competent.
Gigante, Dell, and Sharkey (2011) proposed a five-step process for
giving feedback to students:
1. Identify the expectations for the student. Students need to know
what is expected of them in the clinical practicum.
2. Set the stage for the student to receive feedback from the
teacher and others involved in the learning situation. The authors recommend
beginning with this phrase, “I am giving you feedback” because then students
realize that the information is to help them improve performance.
3. Begin the interaction by asking students to assess their own
performance, which encourages reflection and learning.
4. Describe how the student is performing based on specific observations
of behaviors, which should be shared. It is important to provide concrete
examples of performance and describe specifically how the learner can improve.
5. Ask for input from the learner. In some cases, such as when there are concerns about not achieving at a satisfactory level in the course, a written plan for improvement should be developed with consequences outlined.
Clinical Outcomes and Competencies
There are different ways of specifying the outcomes to be achieved in clinical practice, which in turn provide the basis for clinical evaluation. These may be stated in the form of outcomes to be met or as competencies to be demonstrated in clinical practice. Regardless of how these are stated, they represent what is evaluated in clinical practice.
The outcomes of clinical practice offered in Exhibit 13.1 can be used for developing specific outcomes or competencies for a clinical course. Not all clinical courses will have outcomes in each of these areas, and in some courses, there may be other types of competencies unique to practice in that clinical specialty. Some faculty members identify common outcomes or competencies that are used for each clinical course in the program and then level those to demonstrate their progressive development through the nursing program (Billings & Halstead, 2016).
For example, with this model, each
course would have an outcome on communication. In a beginning clinical course,
the outcome might be, “Identifies verbal and nonverbal techniques for
communicating with patients.” In a later course in the curriculum, the
communication outcome might focus on the family and working with caregivers,
for example, “Develops interpersonal relationships with families and caregivers
.” Then in the community health course the outcome might be, “Collaborates with
other providers, interdisciplinary groups, and community organizations."
As another approach, some faculty members state the outcomes broadly and then indicate specific behaviors students should demonstrate to meet those outcomes in a particular course.
For example, the outcome on communication might be stated as “Communicates effectively with patients and on intra- and interprofessional teams.” Examples of behaviors that indicate achievement of this outcome in a course on care of children include, “Uses appropriate verbal and nonverbal communication based on the child's age, developmental status, and health condition” and “Interacts effectively with parents, caregivers, and the interprofessional team.”
Generally, the outcomes or competencies are then used for developing the clinical evaluation tool or rating form, which is discussed Clinical Evaluation Methods. Regardless of how the outcomes are stated for a clinical course, they need to be specific enough to guide the evaluation of students in clinical practice. An outcome such as “Use the nursing process in care of children” is too broad to guide evaluation.
More specific outcomes such as “Carries out a systematic assessment of children reflecting their developmental stage,” “Evaluates the impact of health problems on the family,” and “Identifies resources for managing the child's care at home” make clear to students what is expected of them in clinical practice. Competencies are the abilities to be demonstrated by the learner in clinical practice. Competencies are the knowledge, skills, and attitudes that students need to develop; they provide the foundation for evaluation (Sullivan, 2016).
For nurses in practice, these competencies reflect the expected level of performance for caring for patients in the healthcare setting. Competencies for nurses are assessed on hire and on an ongoing basis, usually annually, validating that nurses are competent to practice (Levine & Johnson, 2014).
Caution should be exercised in developing clinical outcomes and competencies to avoid having too many for evaluation, considering the number of learners for whom the teacher is responsible, types of clinical learning opportunities available, and time allotted for clinical learning activities.In preparing outcomes or competencies for a clinical course, teachers should keep in mind that they need to collect sufficient data about students' performance of each outcome or competency specified for that course.
Too many outcomes make it nearly impossible to collect enough data on the performance of all of the students in the clinical setting whether they are in a small group with a faculty member on site or are working one-to-one with a clinician. Regardless of how the evaluation system is developed, the clinical outcomes or competencies need to be realistic and useful for guiding the evaluation.
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