Nursing Education and Strategies for Clinical Instruction & Orientation
Strategies for Clinical Instruction and Orientation In Nursing Education
Evaluating student performance, whether for a grade or continued employment, is often difficult to balance with teaching. The question “When does teaching stop and evaluation begin?” can help instructors decide whether learners have met the objectives of the experience.
The instructor may find it arduous to create a learning environment for multiple students with varying needs and skill levels.
Pre- and post-conferences and learning debriefings usually take place before or after a hard day at work. It takes planning and effort to give these sessions value for the student.
Innovative methods can help you provide a safe and relevant education to novice nurses. In the clinical setting, you’ll need strategies that foster learning in a tense environment; safe simulations outside of actual client care; and group exercises in which students learn vicariously through each other’s experiences.
Focus your strategies on critical thinking, priority setting, decision making, and applying theory in the clinical setting. Clinical experience is one of the most valuable tools we have for teaching the nurses of tomorrow and those who already practice.
IDEAS Scavenger Hunts General Description The primary objective of Scavenger Hunts is to help students get comfortable within their surroundings so they can work efficiently and effectively. One of the chief difficulties new employees’ encounters is not knowing where things are or how to access them quickly.
This lack of knowledge may affect their ability to navigate both the physical environment and the virtual world of the computer. Scavenger Hunts provide a safe venue for finding, using, and understanding objects employed in daily nursing practice.
Preparation and Equipment Although it takes a while to make up a Scavenger Hunt, the format may be used time and again to orient new students or employees to a clinical area. You can make up a list of five to six things to find or tasks to be completed in order to meet orientation objectives and develop a sense of comfort in the clinical area. Example of the strategy at work.
Implementation of Clinical Instruction and Orientation Strategy In Nursing Education
Scavenger Hunts can be used in various ways to orient newcomers to a setting. Asking students to find things in the new environment develops their “search and explore” skills. You can ask them to find a straw, locate probe covers for the electronic thermometer, count the Band aids at the client’s bedside, or hunt for other objects used in daily care.
You can take Scavenger Hunts into the area of skills. Your students can learn to use objects they’ll be responsible for in clinical practice. For example, you can ask students to take a tympanic temperature, take an electric blood pressure reading, find an empty crib or bed and raise and lower the side rails, or take their own oxygen saturation reading You can help your students meet the people associated with the unit function.
Ask the unit clerk which phone numbers are used most frequently and where to find the agency directory, how to transfer a call to another phone, or the procedure for printing lab results. Ask the unit pharmacist about the medications most often prescribed on a given unit. Talk with the dietary personnel about their customary times for tray delivery. Talk with a volunteer about his or her role on the unit.
Some components of the unit may be especially conducive to Scavenger Hunts. You can plan searches through the code cart, the medication room, the supply closet, or the utility room. Other searches may be planned throughout the nurses’ station.
You can develop a great learning experience by involving a client’s medical record in a Scavenger Hunt. Students can practice chart information retrieval by hunting for demographics, historical information, or current data before assuming responsibility for client care. Students should be reminded of the confidentiality of client information before this exercise.
Enlist the support of your agency in developing Scavenger Hunts. Have students or orientees visit the pharmacy to retrieve an insert for a common medication administered on a unit, or stop by central supply to ascertain the cost of selected items.
Send students to the medical library for information on a client’s condition, to the lab for the latest clinical results, or to the dietary department to retrieve a menu for a specific medical diet.
If you go this route, you’ll need to spend a little time seeking the assistance of ancillary departments and making sure they won’t feel burdened by sudden multiple visits.
Develop a computer Scavenger Hunt based on all the principles I’ve discussed. Have students sign on to the actual medical record system or a demonstration unit to access specific client information. Ask them to retrieve lab results, admission dates, birth dates, number of scheduled and as-needed medications, or most recent medical orders.
You’ll be helping the students navigate a computer system and client database that are often unique to each clinical area and specialty. Again, client privacy should be reinforced before students access the client record system.
Code, or crash, carts are frequently locked to ensure that they’re stocked completely for emergency use. Create a virtual or video tour of the cart, showing each drawer and its contents as part of the presentation. Include a pre-test and post-test to measure competency in navigating the drawer. Compose a Scavenger Hunt that meets the specific needs of your clinical environment.
It’s essential to keep Scavenger Hunts both brief and fun. Scavenger Hunts that are too long or arduous will frustrate participants. You’re simply trying to acquaint them with the environment enough so that the next time they need to find something, they’ll venture into somewhat familiar surroundings.
Pass the Problem General Description I learned this strategy at a nursing education conference and have found it valuable for clinical groups, especially those new to care planning skills. Attributed to S. Kagan,1 this strategy fosters thinking, team work, and planning. First, I ask my students to take out a clean sheet of paper.
At the top they write their client’s age, sex, medical diagnosis, and a brief background description. Next, they write the primary nursing diagnosis to be used for their care plan. Then the fun starts the paper is passed to each member of the clinical group.
Each member is asked to contribute a client goal and a strategy for that nursing diagnosis. Preparation and Equipment This strategy needs very little preparation. You can develop a Pass the Problem or just have students use blank paper. Example of the Strategy at Work I use the strategy as explained here during a clinical post-conference early in the rotation.
Students are very creative with their ideas and the exercise often fosters a team spirit. Students and orientees learn vicariously about each other’s clients because conversation always happens in response to this exercise. Ideas for Use
Keep the students to a strict time limit so they can all benefit from each other’s contributions. I plan 4 minutes each for an eight-member clinical group, so we’re are done in about 35 minutes. Usually, students can make their comments in that amount of time.
You can use any problem format you like to teach the Pass the Problem concept. Nursing Incoming and Outgoing Classifications (NIC/NOC), client problem lists, medical diagnoses, or patterns of function can also be adapted for use.
Write Pass the Problem at the top of a sheet of paper, or use a form similar to mine, and give each student a copy. This gesture formalizes the strategy and gives it more credibility for some students.
You may want to review the format for client goals and nursing strategies before this exercise. It’s important to make sure that students are clear on these concepts. Client goals are measurable, observable, realistic, and client centred, with a target date. They should begin with the words “Client will” Nursing strategies are individualized, realistic, understandable, specific, and nurse oriented. They should begin with the words “Nurse will .”
Pass the Problem is great for orientees using simulated client building; sharing of care plan skills; and assessment of individual knowledge about critical pathways, care plans, standards of care, and other planning formats.
Students can get their papers back and spend a minute reviewing other members’ contribution. Give them time to clarify information with each other.
If time allows, encourage the students to relate interventions and goals to what they did or witnessed in client care for that shift. They can then evaluate goal attainment and effectiveness of interventions.
Students and orientees can use Pass the Problem to plan care if they’re assigned the same clients the next day. Other students may suggest new goals and interventions, enhancing the clinical experience and the client’s level of care.
Post-conferences and debriefings are a great time to complete this activity. You can use Pass the Problem in connection with the One-minute Care Plan. An important skill for nursing students and new nurses to develop is teamwork. Cooperative Strategies build collaboration, not competition.
They encourage the group to work together rather than in isolation. Foremost, they reinforce the knowledge that teamwork is a lifelong skill vital to professionalism in nursing. Preparation and Equipment The equipment needed depends on the emphasis of your Cooperative Strategy.
By and large, this task requires a longstanding focus on teamwork and collegiality rather than specific supplies. The goal is to create a cooperative atmosphere that can translate to more effective and efficient client care. Example of the Strategy at Work On the first day of clinical work or orientation, assign pairs of students to take care of clients.
Encourage students to assist each other, but not to overwhelm the client with their efforts. The students may take turns checking vital signs, cooperate during assessments so they don’t duplicate efforts, and share in helping the client with activities of daily living.
Reinforce the concepts of delegation and cooperation in this first assignment. As time progresses, make assignments more challenging and independent, always asking students to solicit help as needed. To develop rapport, assign students to neighbouring rooms in the early weeks of rotation or orientation.
Encourage them to help each other, especially when client assignments are demanding. Sometimes we praise students who function well independently. It’s also crucial to reward teamwork in your evaluation of students and orientees. Recognize the importance of working together to accomplish goals.
Cooperative games marketed for young children can set the stage for team building. There are no winners or losers in these games; the object is to work together for a common goal.
Creative strategies described in other chapters of this book are great ways to begin team building in a clinical group, orientation cohort, or any other team in which work may reflect cooperative efforts. Group Concept Mapping, In-Class Debates, and Group Thought are effective ways to foster cooperation and teamwork.
Show a film clip demonstrating team building, such as Remember the Titans, to demonstrate teamwork and collaborative nursing practice (see Short Clips and Film Clips in Clinical).
If you encounter cliques, you may want to assign groups arbitrarily. You can use this tactic to pair more and less talented students and help them build on individual strengths. A student with a sound knowledge base but awkward interpersonal skills may complement a gregarious student who’s less skilled in technical or analytical components.
For nursing clinical groups, you can stimulate a teamwork spirit by such simple statements as, “We don’t leave until everyone is done,” and “We don’t eat until everyone is ready.” Students who finish an assignment early are encouraged to help the others so all can meet the common goal.
Many agencies have client lifting and movement policies to prevent back and other injuries. Using Cooperative Strategies may help new nurses preserve their health as they develop good teamwork habits.
Using pairs, trios, and groups within the clinical group can foster teamwork and collegiality.
Cooperative Strategies encourage novice nurses to consider clients as partners, reflecting the current model of health care. Grand Rounds, Clinical Quick Writes, and Day in the Life of a Client with may be used to reinforce this partnering message. Here’s a great Cooperative Strategy to read to a clinical group, especially one having interpersonal conflicts.
Messages such as these stimulate thought. Discussion may be directed at developing positive relations among individuals in the group. Clinical Quick Writes General Description In this strategy, students are encouraged to develop and use writing skills to describe their experiences in caring for clients.
Clinical Quick Writes may be done during conference or as an independent assignment. Several different versions of this strategy give students a safe opportunity for reflection. Preparation and Equipment No specific preparation or equipment is needed.
You should have a plan for the type of writing project to be assigned. Specific objectives and evaluation strategies should appear in the course guidelines. Example of the Strategy at Work I have found this strategy especially valuable in post conferences. After a long day of clinical work, students may find the post conference tiring.
Allowing time to write and vent some of the day’s emotions provides closure and can make students more responsive to your feedback. The most frequent Clinical Quick Write I use is “Write a Letter to Your Client.” Students assemble in the conference room and get out a paper and pencil.
They spend about 20 minutes composing a letter to one of the clients they took care of during the previous shift. Alternatively, they can write to a family member about their interaction with the client on that shift.
This type of assignment is especially valuable in paediatric and maternity rotations, where family-cantered care is very important. A colleague who uses this strategy in mental health care finds that it stimulates insight and builds empathy regarding psychosocial issues.
You can assign Clinical Quick Writes as journal-keeping exercises. Ask students to spend a minute or longer writing down what happened during the shift. Obviously, this version is a true Clinical Quick Write. Students can use a narrative format to write about their day. Another approach is to write down as many words as they can to describe their experiences.
You can ask students to write a single word or sentence that describes the clinical day. This word or sentence, shared with the group, generates discussion about the day, students’ accomplishments, and goals for future clinical experiences. The conciseness of the exercise helps to focus thought and sharpen assessment and prioritization skills.
The Clinical Quick Write strategy is effective for orientation groups, for team building, for a break in class or a change in atmosphere, and for dealing with controversial topics. For example, if a conflict occurs within the group, have all your students write down their thoughts. Let them choose whether or not to share them with the group.
If a legal or ethical issue arises in the clinical area, students and novice nurses benefit from organizing their own thoughts. Reacting to the issue in writing may offer a chance for you and the group to discuss it. By having students write their personal reactions, you encourage participants to think about their progress and objectives for growth.
Quick Writes help students explore personal issues about their profession. The strategy promotes a metacognitive approach, in which participants are asked to think about thinking.
Provide the opportunity for a “free write” as part of the Quick Write exercise. Simply instruct the students to “write for 5 minutes.” It’s interesting to see what topics they choose and how they use this time as a chance for catharsis.
You may use this strategy daily or weekly and keep the writings in the students’ electronic or hard-copy folders. Students can review the file at the end of the rotation to appreciate their own growth and new breadth of experience. Assignments may be written on paper or submitted electronically.
Ask the students to answer a written question or Critical Thinking Exercise in written format. If a troubling event occurred during the clinical shift, use post conference as a chance for debriefing. Begin this session with private writing time. Conversation will follow from the students’ reactions to their own and each other’s writing.
Always clarify whether Clinical Quick Writes will be private or shared. Writing may inspire personal reflections that students don’t wish to make public. Use Clinical Questioning as a subject for Clinical Quick Writes.
As I’ll discuss later, keeping a journal is an effective way to focus thinking and investigate thoughts, emotions, and experiences. One Minute Care Plan General Description Many of us remember the elaborate care plans we produced in our nursing education. These long, detailed works drew on a plethora of sources and involved hours of work.
Grounded in years of educational practice, this type of care plan provided an excellent learning experience. However, being specific to the care of one client and requiring a long preparation with extensive rationales, it lacks practicality in today’s busy nursing practice. The One Minute Care Plan streamlines the time and pares down detail.
This strategy gives students a useful and realistic means of organizing their thoughts, using the nursing process, and creating an accurate profile of a client. Preparation and Equipment You need to decide what client information is essential in clinical rotations.
The setting, the objectives of the rotation or orientation phase, and your personal priorities can all influence your decision. You may assign the One-Minute Care Plan with explicit instructions or develop a form to be filled in like a worksheet. I’ve provided an example, but you can make up your own or adapt this one for your needs.
I developed this form for my clinical groups after reading The One Minute Teacher2 by S. Johnson and C. Johnson. This book is part of the “One Minute” series, and I recommend it highly. According to the author and the teacher provides the framework for learners to teach themselves. The One-Minute Care Plan developed from that idea.
Add medication sheets, lab data, and assessment information as needed to make sure the students have a good understanding of the client’s condition.
Use the following guidelines to ensure a comprehensive client profile:
Allergies
Diet (type and how tolerated)
Fluid requirements (based on weight and age or norms)
Reason for hospitalization
Other medical problems
Planned treatments (surgeries, therapies)
Current physiological status: Vital signs, pain status, oxygen saturation, review of systems
Lab and radiological findings
Current psychosocial status (fears, stressors, coping)
Family involvement (visiting, participation in care)
Use this form during pre-conferences to prepare students for the clinical day. You may need to help students choose a nursing diagnosis; they sometimes have trouble anticipating nursing needs on the basis of a medical diagnosis or condition. Confer with them about care priorities, their role in the clinical experience, and their goals for the day for the client.
Have students take notes on the form during report periods. I’m often surprised that when staff members give a report, students often either write nothing or write selectively. The One-Minute Care Plan may help them take down information that will affect care planning for their clients.
Encourage the students to use the One-Minute Care Plan as a worksheet for ongoing assessments, developments in care, and news to be passed on in report. The strategy helps students decide “things to check,” such as turning, medications, and scheduled treatments.
This strategy also provides the framework for reporting to the staff. Students often just say to the nurses, “We’re leaving,” without realizing that certain information needs to be passed on.
The One-Minute Care Plan allows students to reflect on the care they’ve provided and to think about potential revisions. After using the strategy to look back on the day, students can write in their journals about objectives achieved, potential areas of concern, and personal goals for growth (see Ah-hah Journals).
Establishing a system of organization is one of the biggest challenges for students and orientees. One-Minute Care Plans help them organize their day and their care. These plans can be adapted for individual and agency needs.
Students caring for multiple clients may want to restrict their care plans to a brief client profile and one nursing diagnosis with goals and interventions. Ah-hah Journal General Description The journal is a common method by which clinical instructors gauge student progress and get a “feel” for the student’s thoughts and emotions.
Less often, agency educators use it to assess the progress of new orientees. The ease and perceived value of journal keeping varies among individuals. For some students, writing even five sentences is a painful experience.
For others, page limits may be necessary to rein in their lengthy writing. The value of conventional journal keeping is questionable, especially if journals become chronological records of “things done” rather than “lessons learned.”
I still remember a five-page student journal that began, “At 6:45 a.m. I hung up my coat and prepared for my observation day in the ICU.” Although this journal recounted every event of the day, it gave me no means of assessing critical thinking or any clue to the student’s emotional side. Hence the Ah-hah Journal.
This strategy provides a glimpse of an event, giving some idea of the student’s thoughts, emotions, and reflections on lessons learned during the clinical experience. Preparation and Equipment Put Ah-hah Journal guidelines in your class packet or syllabus.
Assign a component of the class grade to this assignment, allowing for frequency, estimated page length, and the points assigned to the exercise. For orientation groups, provide guidelines to validate the use of Aha Journals as a legitimate way to document progress throughout the orientation period.
Make sure you read all journals, comment about the student’s observations, and demonstrate support of their reflective learning. Students provide more detail and share more readily when they think someone cares and is listening.
By describing events and thoughts, students are able to use Ahhah Journals as learning exercises, which will help them generalize learned lessons to future events.
By analysing contributing factors, students learn to appreciate the complexity, and the often competing priorities and perspectives associated with today’s health-care environment.
Make sure your students understand the format of the journal it’s not a record of the day or a validation of experience, but a reflection on lessons learned.
Surprisingly, some students go through an entire clinical day and claim, “I had no Ah-hahs today.” I always find this hard to believe. It’s important for students to see Ah-hahs as both positive and negative, or even neutral, events.
I tell students to think about the day and write about something they found surprising, or something they didn’t know or hadn’t thought of before the clinical experience. Michele Deck3 describes “whack on the side of the head” experiences as those in which the individual is changed or inspired by an event.
Encourage students to find material for Ah-hah Journals in everyday life, and especially in their clinical work. For orientees, include Ah-hah Journals as part of weekly debriefings. Share common observations with the orientation group or allow orientees to disclose their own insights.
Ah-hah Journals give you a great way to observe how students are doing in various sites or on different units. Observational experiences, such as the operating room, emergency department, and intensive care unit, are candidates for these journals.
Ah-hah Journals let you “keep your finger on the pulse” of a clinical or orientation group. The process can uncover issues that require aggressive interventions, such as unit conflicts, staffing issues, or manager problems. This strategy can help you resolve conflicts sooner rather than later.
Creative Lab Skills General Description The nursing laboratory assists students to develop skills in dealing with heightened clinical acuity and more complex psychomotor skills. The number of nursing skills to be learned is always increasing. Nursing and staff development instructors must struggle to find effective teaching strategies that keep pace with the student’s new level of learning.
Although a comprehensive discussion of teaching laboratory skills is beyond the focus of this book, several strategies can aid in teaching and reinforcing those skills. The emphasis is on learning the steps of a skill, understanding its scientific basis, and demonstrating it safely in the lab or the clinical area.
Lab skills focus the sense of accomplishment for a novice nurse competent completion of these skills gives students more satisfaction than other cognitive achievements do. For this reason, nursing instructors should be sensitive to the stress involved in learning motor skills.
Creative Lab Skills help students learn them as thoroughly and expeditiously as possible. Preparation and Equipment Laboratory experience takes a fair amount of preparation. According to which strategy you use, you may need skills checklists, policy or procedure guidelines, and the equipment to practice the skills.
Example of the Strategy at Work After growing numbers of students overwhelmed our old methods, our program searched for effective and cost-efficient ways to teach lab skills. Each course has certain skills assigned to it.
Students attend the simulation resource canter for practice and skill evaluation. The lab is staffed by a lab coordinator, who fosters the learning environment. Several aspects unique to our lab are noted in the Ideas for Use section.
Audio visual resources help in demonstrating lab skills. Use DVDs with both written content and movie clips. This approach appeals to diverse learning styles and allows you to repeat the demonstration.
Each student purchases lab supplies in a duffel bag. The equipment company allows us to choose the supplies, which then belong to the student. The students can practice in the lab while you evaluate their progress. Having their own equipment also lets them try out their skills at home. This method is especially valuable for skills that take practice, like sterile gloving.
A lab coordinator developed learning bins, which sorted the equipment needed for different skills. Students can use the contents as an adjunct to their personal equipment.
Encourage the students to use peer teaching and learning as part of their lab skill training. Rather than demonstrating all the skills yourself, let the students actively coach each other using their skills textbook.
Have them open the book at the mannequin’s bedside and assist each other through the steps of a skill, providing feedback as needed. This peer teaching is valuable for both learner and coach. It ensures active integration of the skill, rather than the passive learning that follows a simple demonstrations.
Laboratory textbooks and checklists of skills are available from multiple publishers. You can either use these or make up your own checklists, though doing so can be very time consuming.
One faculty member suggested that students wear the school uniform when in the resource simulation lab. Uniforms foster a professional atmosphere in which the students “feel like nurses” and behave accordingly. Uniforms also help them regard the lab as an integral component of the clinical experience.
Student teaching assistants have made a positive difference in our program. Having senior students assist junior students benefits both parties. More details about this program can be found in an article entitled “Benefits of Using Undergraduate Teaching Assistants Throughout a Baccalaureate Nursing Curriculum by Herrman and Waterhouse.
Actors posing as clients can be useful in teaching physical assessment skills to prelicensure students and advanced skills at the graduate level. Schools may employ these actors or ask students to cover the cost as part of their course fees.
For orientees and nurses new to a specialty, engage more senior clinicians to teach, assist with practice, and evaluate psychomotor skills. In clinical agencies with explicit procedure manuals, ensure that skills are taught and learned according to agency policy (see Active Reading Conference).
The use of simulation mannequins has revolutionized the way nursing skills are taught in both schools and the clinical area. Simulators can be programmed to provide more than just a practice medium for a specific skill. They also can replicate a client’s response in a given situation.
Numerous resources exist for establishing and maintaining a simulation lab. Educational research has begun to develop an evidence basis for the use of simulators in nursing education across the practice field.
This strategy is just what it sounds like. Equipment Conferences acquaint students with equipment they’ll use in the clinical area. Each agency has its own type of equipment, which may differ from what students used in previous lab work. This strategy reviews the basic workings of a piece of equipment and examines the nuances of a specific machine or set of supplies.
Conferences take place away from the active clinical area. Thus, they provide a safe opportunity to discuss the policies and procedures involved in operating and troubleshooting equipment. Preparation and Equipment Plan the time and place for the conference and bring the equipment with you.
In some cases, you’ll need other supplies to put the equipment to work and allow students to practice. Example of the Strategy at Work Although students practiced clinical skills repeatedly in the lab, they consistently expressed misgivings about their skills.
I chose to incorporate tracheostomy care and suctioning into their orientation day. We used several mannequins with simulated tracheostomies and portable suction to allow students to practice the skill in pairs. The students practiced tracheostomy care according to the agency policy, which was slightly different than what they had learned in lab.
They changed tracheostomy ties, did the suctioning procedure, and bagged the “client” to provide oxygenation between suctioning attempts. They rotated among the stations and practiced each skill. Students were encouraged to teach each other and provide feedback.
An earlier tour of the unit had shown them how many clients were ventilated by tracheostomy. Seeing the wide clinical application of this skill helped them appreciate its relevance and immediacy. Once I taught on an oncology unit, in which many clients had central venous access devices.
One of our responsibilities was changing the central line dressings. We used the unit’s format for teaching families: venous devices were accessed from staff development and inserted into placemats purchased at a local bargain store. The students brought central line dressing change kits to practice with.
First, we all did the procedure together, discussing sterile technique, principles of asepsis, how to change a dressing on a moving client, and troubleshooting line complications. Then each student was able to change the dressing on an individual placemat.
In both examples, students were active during the conference period and reinforced a key skill for the clinical area. They could then be held accountable for that skill when the time came to provide it as a part of client care.
Conduct Equipment Conferences early in the rotation to ensure competency before your students begin caring for clients. Start with less complex equipment, such as the pulse oximeter. Pass the sensor around the room to have students spot-check themselves. Move on to more complex skills throughout the rotation.
If you can, obtain the equipment instruction manuals or agency policies to establish the procedures and show the students where they can obtain additional information about the skills.
Identify the key skills the students will need on the unit: inserting Foley catheters, administering IV medications, using a feeding pump to administer tube feedings, using IV infusion pumps, caring for a client with a ventilator, changing complex dressings, and obtaining and interpreting ECG strips.
These and many other skills can be reviewed in the clinical area if students’ motivation is high and agency-specific equipment is available. Solicit feedback about what skills the students would like to review in conference time. As the rotation proceeds, poll them to find out what equipment or skills they find puzzling and build an Equipment Conference around those needs.
Conferences may be held before, during, or after clinical or orientation days, or during other clinical meetings. Equipment Conferences may be instructor led or student led according to the needs of the group and the way students are evaluated. The Equipment Conference may be assigned to each student as part of the course grade.
Enlist other professionals at the agency to help with Equipment Conferences. Respiratory therapists, dieticians, IV specialists, unit instructors, and staff development personnel can provide a high level of expertise concerning skills and agency specific procedures.
Active Reading Conference General Description One surprise new nurses and nursing students face is the realization that there’s more than one way to do certain things. Sometimes different procedures can accomplish the same skill with the same outcome.
Another surprise for students and orientees is that clinical agencies have explicit procedures and standards of care, much like the skills texts and care plans used in nursing school. The Active Reading Conference reveals the resources available in a clinical agency and reinforces the importance of those documents for safe practice.
This strategy requires both students and faculty to be vigilant for frequently used skills or common nursing problems in the specific clinical area. The instructor assigns each student to seek out a procedure or the standard of care for that procedure. Students read this to the group during conference time.
Active Reading calls for students to condense and summarize the information, making sure to emphasize key points, focus on nursing priorities, and allow for questions and comments.
Find the agency protocols and show them to the students early in agency orientation. Refer students to those documents frequently to ensure their use during clinical practice. Many agencies have converted their procedures and standards of care to an electronic format, available through the facility’s network.
I was surprised to find that students often didn’t know what resources were available. Then I realized that I, as their clinical instructor, was responsible for showing them these documents. That’s how the Active Reading Conference was born.
A student needed to insert a nasogastric tube into a client and panicked. The student had learned the skill in the lab and been tested successfully but now the time had come to really do it. We got out the agency manual, at the time bound in a notebook, read the procedure together, and completed the skill.
The student, who marveled at the resource and how much it had helped with the task, wanted to share the experience in post conference. The student copied the procedure and presented key points of the policy to fellow students while discussing the experience of inserting the nasogastric tube.
Have students use a highlighter to emphasize key points of the standard of care or procedure before they present it to their peers. Tell students the point of the strategy to emphasize key concepts and focus on nursing priorities.
The word “reading” confuses some students, who think they’re supposed to report on the document verbatim. Pass out company equipment handouts or other materials to help students learn about new equipment.
Post Active Reading Conference information in the restrooms. One participant called this method “Elimination Illumination.” This strategy can be incorporated into mandatory skills and orientation to ensure compliance with agency policies.
The Active Reading Conference is especially valuable if the student assigned to read the case will be caring for a client needing this skill or care plan. Encourage the student to enhance the presentation with personal experiences. Students enjoy sharing insights what it was like to do the procedure, the challenges encountered, and the sense of accomplishment following the task.
The discussion can include client responses to the procedure and other nursing interventions, such as teaching, comforting, and client support.The Active Reading Conference may be effective in a service setting, where seasoned nurses forget the trepidation that skills can arouse in new nurses. Novices can share experiences and learn vicariously from each other.
An important facet of this strategy is the legal and accrediting aspect of agency procedures and standards of care. Students also need to consider the ramifications of not knowing, not following, or deviating from agency protocols.
Orientation groups can use this strategy to introduce procedures and standards of care to new employees. Active Reading Conferences or debriefings may be used to emphasize key skills and conditions the new nurse will encounter in the clinical area.
Many organizations have their policies, procedures, and standards on their intranet, allowing students and orientees to download documents as needed. Grand Rounds General Description Grand Rounds is a common strategy many of us remember from our days in school. However, some conditions have changed.
Clients now expect to be informed about their care; at the same time, they expect that information to remain confidential. We’ve had to adapt our methods to meet the needs of students and orientees while respecting those of the client. Grand Rounds requires each student to present cases either at the client’s bedside or outside the room.
Students are asked to provide a brief description of the client’s issues and diagnoses, the course of treatment, and the nursing priorities and implications. An important component of this strategy is to seek the client’s and family’s permission before undertaking it. Preparation and Equipment No equipment is needed.
You should preview the clients for whom students will present Grand Rounds. Higher acuity levels reflect an increase in the number of clients who may be too sick to qualify for this strategy. Students should understand how to speak about clients in their presence and what information to present.
You can give them guidelines, such as a list of needed information: Client age, sex, and diagnosis; current course of treatment; nursing issues; and priorities at this time. Example of the Strategy at Work Grand Rounds is especially valuable when students have gotten comfortable caring for and interacting with clients.
Toward the end of the rotation, they generally have the knowledge and poise to undertake the strategy. I let the students decide whether to conduct the Grand Rounds at the client’s bedside or at the door. I’ve also found it important to secure the permission of the nurse manager.
Because of HIPAA and confidentiality restrictions, some leaders prefer that we use a conference room for these discussions. In such cases, I assign two or three Grand Rounds per clinical day. I ask all the students to introduce themselves to the clients we’ll discuss that day, as well as to the clients’ families.
This tactic gives all the students a visual picture of the client to go along with the presentation. I also reinforce the need to be polite, caring, and respectful during all client interactions.
Questions addressed in the Clinical Questioning strategy can become part of the student’s presentation in Grand Rounds. Not only should we ask the client’s and family’s permission, but we should also ask their perceptions and priorities at this time: What is troubling you most? What do you expect to get out of this hospitalization? What do you need nursing to assist you with? These questions and others include clients as true partners in care.
Some instructors find it valuable to include physical and other assessments as part of Grand Rounds. This method enlists clients’ help in teaching the students or orientees. Again, it takes a special client to agree, and the direction of Grand Rounds must change if the client becomes uncomfortable.
Show the film clip from Patch Adams in which Patch so adeptly rehumanizes rounds by asking the client’s name. Spend some time discussing that client’s reactions to the other physicians and then to Patch as a way to model behaviours.
Grand Rounds are meant to focus on client specific information. This is not the time for elaborate discussions of pathophysiology or treatment options. For more in-depth discussions, see One minute Class and Student led Seminars.
Students may share their Ahhahs, their nursing priorities in the care of selected clients, and what they would do differently if they cared for the client again. This information must be shared judiciously if the rounds take place at the bedside.
Use the One Minute Care Plan to guide the structure of Grand Rounds if you would like to try a different format.
Grand Rounds offers a great opportunity for students and orientees to present with knowledge and a sense of accomplishment. Talking about the client and answering questions gives students a chance to succeed and feel good about their progress. It’s important for instructors to take a back seat at this time and allow the students to teach each other.
Give your opinion if have any.