Patricia Benner, R.N., Ph.D. FAAN
…in the current nursing education climate, faculty need to use a wider repertoire of clinical models and strategies to foster the depth of student learning and their development of clinical judgment. Kathie Lasater, EdD, RN, ANEF; Ann Nielsen, MN, RN Jo. of Nursing Education, 8,2009 Vol. 48, p. 446.
Developing astute clinical judgments about complex clinical concepts and phenomena require deeper learning in clinical assignments that focus on comparing and contrasting patients who demonstrate the clinical phenomena of concern. For example, focusing a concept based clinical assignment on fluid and electrolyte balances in patients in different age ranges, and or clinical conditions, can illuminate the interactions and monitoring issues; for example, with the patient with congestive heart failure, with renal failure, patients who require diuretics and so on. Lasater and Nielsen (2009) point out that the traditional model of total patient care may not allow deeper learning focusing on the clinical manifestations and care of patient with fluid and electrolyte imbalance. In this month’s video, Linda Brown, R.N., M.S., demonstrates how she develops and works with assigning students in-depth study of key concepts during their clinical time. We observed her concept based class on Electrolyte and Fluid Balance in a pediatric population.
Linda Brown’s class is a fine example of a classroom innovation that’s part of OCNE. The Oregon Health Care Consortium (OCNE) has created a shared curriculum and joint matriculation into the Consortium Associate Degree Schools and the Oregon Health in order to create a seamless transition for Associate Degree Nursing Students to complete their Baccalaureate Degree in a timely and planned way. This transformational change is well known for its success in integrating and streamlining progression from Associate Degree to Baccalaureate Degree education in nursing, and for increasing the BSN degree progression rate for Associated Degree students. OCNE is perhaps less well known for the innovations in Faculty Development and innovation in nursing education pedagogies. EducatingNurses.com has been illustrating the teaching learning breakthroughs through excellent teaching examples in the OCNE. Clinical education was a major focus in the OCNE efforts to improve learning in students’ clinical judgment and ability “to think like a nurse:”
Clinical Education Redesign – Changing the framework of clinical from training to a learning laboratory
- In conjunction with practice partners move from random access of clinical learning experiences to purposeful activities
- Make best use of clinical and lab resources across the state
- Transparency in expectations based on competency benchmarks
- Incorporate simulation facilities on every campus OCNE Website
As Dr. Christine Tanner noted in her EducatingNurses.com video on OCNE, little innovation has occurred in clinical education since the introduction of whole patient care. Whole patient care replaced a functional nursing approach to different areas of nursing assessments and interventions, e.g, administering medications, checking vital signs. It was recognized that as the complexity of nursing care and nursing clinical judgment became more critical to a patient’s well-being, that dividing tasks among multiple nurses simply did not allow for careful clinical evaluation of patients over time. Now that most nursing care is based on adjusting therapies, based upon a patient’s particular responses, titrating medications, assessing patient trends and so on; nursing students need to learn deeply about changes in patients clinical condition, based upon their disease and therapeutic regimens. This cannot be reliably accomplished by the “total patient care model” alone. While students still need to deliver primary total patient care to patients, they need to deeply study the clinical implications of different clinical phenomenon, such as pain management, immune-suppression, sepsis, electrolyte-fluid imbalance in varying patho-physiological conditions. Clinical assignments based on in-depth study of a particular clinical phenomenon, and associated patho-physiological concepts have been enthusiastically received by the OCNE students. As Carol Thorne points out in her EducatingNurses.com interview, students requested that concept-based clinical assignments be continued in the second year of their clinical. One of the problems with total patient care clinical assignments is that there is little opportunity to control the students’ in-depth learning about essential areas of clinical judgment, such as fluid and electrolytes, oxygenation and so on.
Lasater and Nielsen (2009) describe concept-based clinical Assignments as follows:
Concept-based learning activities provide students with opportunities to study basic nursing and physiological concepts in depth without assuming responsibility for total patient care (Heims & Boyd, 1990; Nielsen, 2009). This supports learners’ need for dependence early on, preparing them for more self-directed learning as they move through the program (Grow, 1991). Subsequently, students should be able to apply conceptual learning in more complex total care clinical experiences, providing the sequential building on concepts so that new ideas can be integrated with previous learning to promote student learning (Fink, 2003).
Concept-based learning activities are a structured approach to study one discrete aspect of patient care, such as oxygenation or pain management (Heims & Boyd, 1990; Nielsen, 2009). Concept-based learning activities follow a study guide, using the Tanner (2006) Clinical Judgment Model as a framework.
Providing an Opportunity for Students to Compare and Contrast Patients by Focusing on Selected Clinical Phenomena
As Clinical Teacher Linda Brown points out, the student’s clinical judgment learning is greatly enhanced by comparing and contrasting patients who all have fluid and electrolyte imbalances. These focused comparisons between patients allowed for situated coaching, and the development of clinical judgments in particular clinical patients. Lasater and Nielsen (2009) found that the concept-based clinical students scored statistically higher in all four phases of the Tanner Model of Clinical Judgment as well as total clinical judgment. Qualitatively in focus groups, concept-based clinical students pointed out that learning guides that prepared the students to systematically explore the clinical implications of the particular clinical concepts were essential to their learning. Students also highly valued the cooperative learning activities. The students highly valued the more difficult focused attention on clinical assessment and judgment in relation to the particular clinical concept:
One student stated that concept-based learning activities made her think “in a way that made the potential problems associated with these altered conditions clear and understandable.” Another participant commented that completing the concept-based learning activity was like “pulling teeth,” but expressed appreciation for the depth of study with regard to the concept. (Lasater & Nielsen, 2009, p.443)
Concept-Based Clinical Assignments Shift the Focus to Clinical Judgment instead of a “Task-Focus”
Novice students who are doing “total patient care” often do not see the trees for the forest. They do not yet have a sense of salience about what is most important or least important in a particular clinical situation. By taking away the requirement of direct patient care, and placing the focus on the clinical judgments that nursing care requires, students begin to experience the clinical judgments required of them as nurses. A concept-based clinical provides a wonderful opportunity to learn to make a clinical judgment case to other clinicians based directly on the patho-physiological implications of patient data. Experiential learning can be shared in the clinical debriefing session more effectively because the focus is narrowed down to comparing and contrasting the clinical implications of a particular clinical phenomenon in different patients. In their discussion of the varying cases, students may encounter clinical misunderstandings of the patient’s situations. This teaching moment provides a safe opportunity to make qualitative distinctions between radically different clinical causes, such as pump failure and volume depletion, and sources of hemodynamic instability where students may have been making mistaken attributions of physiological causes.
Concept based clinical assignments can help link practice and education (Benner, Sutphen, Leonard, & Day, 2009). Students must have clinical learning opportunities that allow them to make early and accurate clinical judgments about changes in patients’ acute, complex clinical conditions. Such deep learning requires focused comparisons in clinical manifestations of phenomena such as hemodynamics, oxygenation, perfusion, early recognition of sepsis and so on. Focused clinical assignments around these and other critically significant clinical phenomena that commonly occur in both acute and long term care settings can better prepare students and graduate nurses to recognize and act on significant clinical alterations in their patients.
Last month we focused on increasing the reliability of nursing education. This month we offer concept based focused clinical assignments as a step in the right direction. Study guides to focus the students’ learning and enrich their assessments, critical thinking, and clinical questions are essential to effective concept-based clinical assignments. Concept-based clinical assignments can reduce the gap between knowing “ that” and superficially knowing “about” to situated knowing “how” and “when.” Knowing how and when to draw on particular knowledge, science and theory requires productive thinking and situated teaching and learning. Now that we have evidence that clinically-focused assignments improve clinical reasoning, we have a mandate to continue to develop and enrich learning in concept-based clinical assignments.
Benner, P., Sutphen, M., Leonard, V., Day, L. (2009) San Francisco: Jossey-Bass, Carnegie Foundation (Palo Alto, CA)
Fink, L.D. (2003). Creating significant learning experiences: An integrated approach to designing college courses. San Francisco: Jossey-Bass.
Grow, G.O. (1991). Teaching learners to be self-directed. Adult Education Quarterly, 41, 125–149. doi:10.1177/0001848191041003001
Heims, M.L. & Boyd, S.T. (1990). Concept-based learning activities in clinical nursing education. Journal of Nursing Education, 29, 249–254.
Lasater, K., Nielsen, A. (2009) Jo. of Nursing Education, 8, 209 Vol. 48, pp. 441- 446.
Clinical Education Redesign – Changing the framework of clinical from training to a learning laboratory Oregon Nursing Education Consortium Website: http://www.ocne.org/about/MajorElements.html 5-19-2016
Nielsen, A. (2009). Concept-based learning activities using the clinical judgment model as a foundation for clinical learning. Journal of Nursing Education, 48, 350–354. doi:10.3928/01484834-20090515-09
Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45, 204–211.