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Implementing Quality and Safety Education for Nurses in Postclinical Conferences: Transforming the Design of Clinical Nursing Education

Mohn-Brown, Elaine EdD, RN, CMSRN

doi: 10.1097/NNE.0000000000000410
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Postclinical conferences are an essential component of clinical nursing education. Numerous constraints including the rapidly changing clinical teaching environment and the struggle to secure clinical placements are affecting the use and purpose of postclinical conferences. This article describes 1 faculty member’s approach in designing and implementing a teaching strategy to integrate Quality and Safety Education for Nurses and concepts from a concept-based curriculum into a unique clinical seminar format.

Supplemental digital content is available in the text.

Author Affiliation: Nursing Faculty and Second-Level Program Chair, Nursing Program, Chemeketa Community College, Salem, Oregon.

The author declares no conflicts of interest.

Correspondence: Dr Mohn-Brown, Chemeketa Community College, 4000 Lancaster Dr, Salem, OR 97309 (elaine.mohn.brown@chemeketa.edu).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com).

Accepted for publication: May 15, 2017

Historically, clinical teaching has been and remains an essential foundation of nursing education to meet program and student learning outcomes. However, planning and implementing appropriate and quality clinical teaching experiences for prelicensure nursing students continue to challenge nursing faculty. Constraints range from inadequate clinical teaching placements for the increasing numbers of students to the lack of qualified nursing faculty. The development of new clinical nursing education sites often means increased travel, orientation time, and scheduling difficulties for faculty and students in addition to less time for mentoring new clinical faculty.1 Clinical teaching experiences have changed from 8-hour shifts to 6-, 10-, or 12-hour shifts that may include night shifts, weekends, and holidays, affecting arrangement of postclinical conferences.2 Nursing staff are expected to supervise or precept nursing students from multiple nursing programs without receiving concise learning guidelines and goals for students, while simultaneously managing care of high-acuity patients.3 The increased demands on staff can create an unfriendly or poor-quality learning environment that negatively impacts student learning.1,3

Coinciding with clinical nursing education issues and concerns is the demand to improve the quality and safety of health care. Seminal reports from the Institute of Medicine (IOM) called on all health profession educational programs to redesign curriculum to increase focus on quality and safety.4,5 In response, the Quality and Safety Education for Nurses (QSEN) competencies were formulated. Quality and Safety Education for Nurses offers a foundation for developing purposeful clinical teaching and related clinical nursing education activities to promote quality and safe care.6 Although postclinical conferences provide a myriad of opportunities to enhance student self-reflection and application of problem-solving techniques, they often lack clear purposes or focus.7 Postclinical conferences framed in the QSEN competencies can cultivate students’ understanding and use of evidence-based quality and safety standards in their practice.

To address the IOM reports and dilemmas created by challenges in clinical nursing education placements, faculty in a 2-year ADN program redesigned postclinical conferences to a clinical seminar format. The clinical seminar was developed for second-year students enrolled in an ADN program housed in a community college. The nursing program maintains approval from the State Board of Nursing and accreditation from the Accreditation Commission for Education in Nursing. The nursing program offers practical nursing and an ADN curricula. After the first year of the program, students can take the NCLEX-PN examination; students completing both years are eligible to complete the NCLEX-RN examination.

All nursing courses consist of didactic skills, laboratory activities, simulation, and clinical components. Only full-time faculty members teach course components and assume responsibility for teaching and supervising 8 students in a clinical group. Clinical nursing education experiences for second-year students occur in acute care settings for one 12-hour day per week but on different days of the week, including Saturdays. This schedule reduces the burden on clinical facilities and accommodates students’ need to arrange school, work, and childcare schedules. Although the shift to 12-hour clinical teaching experiences meets clinical partners’ needs, the clinical arrangement fails to meet the required course hours, leading to creation of a new teaching and learning strategy, namely, the clinical seminar.

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Clinical Seminar

The impetus for changing from the traditional postclinical conference after the clinical day to clinical seminar, a 3-hour event on another day, was 3-fold. Approximately 5 years ago, a primary clinical facility decreased the available student placements for 8-hour clinical days. Previously, students were scheduled for two 8-hour clinical days per week. Inadequate 8-hour clinical shifts necessitated rescheduling students to one 12-hour clinical day per week to increase the number of student placements. Second, moving from 16 hours of clinical instruction per week to 12 hours created a 4-hour deficit of clinical time per week, reducing the total clinical time required for the course credit hours. Third, scheduling postclinical conference after the 12-hour clinical day seemed unrealistic for students and nursing faculty.

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Clinical Seminar Design

Rethinking time, setting, and purposes of postclinical conferences offered an exciting yet challenging opportunity for the faculty. Yehle and Royal8 proposed changing postclinical conferences from the traditional conference after clinical nursing education experiences to a different time and setting. Having all second-year faculty teach clinical experiences allowed a consistent academic team to participate in the redesign of the postclinical conference. Because the clinical teaching schedule changed less than 1 month before clinical experiences began, there was limited time to develop a well-planned new conference format. The postclinical conference was renamed to clinical seminar, but adjusting to a radically different clinical teaching schedule reduced the faculty’s creative efforts. This resulted in the original clinical seminars often resembling previous postclinical conferences with only a new time and setting. Faculty realized that future clinical seminars needed structure and focus to meet course and program outcomes.

During the next 5 years, clinical seminars became more than simply changing the place and setting. Students were scheduled for a 3-hour clinical seminar on campus for a total of 4 seminars during the term. Because the 12 clinical seminar hours insufficiently met all of the required clinical hours, 2 skills laboratory activities were also added to enhance patient assessment and prioritization skills. The overarching framework for each clinical seminar was based on incorporating QSEN competencies. The following clinical seminar goals were developed: (1) foster students’ critical thinking about their patient care, (2) increase knowledge and application of QSEN competencies, (3) apply theory to clinical experiences, and (4) enhance leadership skills. Rather than relying on events of the clinical day to determine the content of the clinical seminar, learning activities were planned ahead. Purposeful activities focused on correlating theoretical concepts to clinical experiences, encouraging student leadership and presentation skills, and promoting reflection on patient care delivery. To focus and motivate student learning, a seminar guide was developed and given to students before each clinical seminar.

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Clinical Seminar Guide and Content

To facilitate students’ advanced preparation and allow time to reflect on their previous clinical experiences, the author developed a seminar guide, which students received 1 week before each clinical seminar. Each guide outlined the focused QSEN competencies, the students’ assignment date and guidelines for their student-led patient discussion, and concept-focused learning activity (see Figure, Supplemental Digital Content 1, http://links.lww.com/NE/A376). At the first clinical seminar of the term, students were assigned a presentation date so that, at each subsequent clinical seminar, 2 to 3 students presented one of their patients. Each student-led patient discussion lasted approximately 30 to 40 minutes and included a focused handoff report, patient presentation, and exploration of care. Patient presentations involved answering QSEN-focused questions to assist students’ reflection on their nursing care.

The discussion began by students giving a 2-minute focused handoff report for their patient. During previous simulation experiences, students practiced handoff reports to student peers using Situation, Background, Assessment, and Recommendation (SBAR). In the clinical setting, students were required to give handoff reports or SBAR to faculty and staff nurses. However, the actual experience was often sporadic, fraught with fear and intimidation, and sometimes considered meaningless. Although staff nurses knew that effective communication was essential to quality and safety, they discounted the student’s information or rushed them to finish their handoff report. Each health care facility where students were scheduled used a different handoff format, complicating students’ ability to give an organized report.9 Informal feedback from staff nurses indicated frustration with students’ reports due to incompleteness, disorganization, or excessive length.

Clinical seminar offered students a safe environment to practice handoff reports. It also provided an opportunity for their peers to practice listening to report and to learn strategies for gleaning the most important pieces of information. Frequently, students struggled with capturing essential report data because of unfamiliar terms, incomplete information, speed of report, or disorganization. With faculty guidance and repetition, students developed a structured process to improve future reports. After handoff report, the faculty leader either asked for student volunteers or randomly selected students to furnish both positive and constructive feedback based on guidelines given in the seminar guide (see Figure, Supplemental Digital Content 1, http://links.lww.com/NE/A376). Students recommended suggestions for improvement with the aim of learning to value peer feedback.

After the student-led discussions, a specific learning activity was implemented to relate concepts and theoretical content presented in the current nursing course. For example, 1 lecture focused on the concept of fluid and electrolyte imbalances. After classroom discussion and learning exercises on the concept, a clinical seminar provided an opportunity to explore and reflect on its application to different types of patients seen by students during their clinical nursing education experiences (see Figure, Supplemental Digital Content 1, http://links.lww.com/NE/A376).

Other clinical seminar learning activities included practicing complex psychomotor skills that incorporated applicable QSEN competencies. For example, 1 clinical seminar activity involved administration of intravenous push (IVP) medications. On the basis of a typical clinical group of 8 students, 8 different IVP practice stations with mini-scenarios were set up at individual manikins in the skills laboratory. A handout with each mini-scenario and IVP administration questions was placed on the bedside table by the manikin. Faculty with their own clinical group assigned 1 scenario per student. Students solved 1 scenario and practiced the skill on their own, receiving faculty feedback as needed. After each student solved the assigned scenario, the other clinical group members rotated to each practice station. At each station, the assigned student explained and demonstrated the steps used to solve the scenario. Students also identified evidence-based practice standards, safety concerns, and patient-centered care concepts used to complete the station exercise (see Figure, Supplemental Digital Content 2, http://links.lww.com/NE/A377). If key points were overlooked, faculty encouraged further input from group members to show the value of collaborating with team members.

As illustrated, a variety of learning experiences were suitable for clinical seminars. Selecting appropriate clinical seminar foci and activities best met student needs when correlated to course and program outcomes. Teaching strategies were considered for their effectiveness in moving students beyond comprehension to application, analysis, and evaluation of patient care. For instance, when student performance demonstrated an opportunity for improvement in meeting QSEN competencies, faculty had students anayze why and explore alternate ways to meet them. Students’ thinking was broadened by posing high-level questions such as (a) “How and why would you prioritize care differently?” and (b) “What patient and family responses indicated effective care? How would you adjust the plan of care to increase effectiveness?” Regardless of the teaching strategies or clinical seminar format, the underlying intent was to promote the development of students’ clinical judgment.3

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Faculty and Student Roles

All faculty were responsible for scheduling clinical seminars for their clinical group, designing educational activities, and determining the focus and concepts based on the nursing course outcomes. Depending on the students’ clinical schedule, faculty scheduled the four 3-hour clinical seminars after either didactic classes or skills laboratory during the academic term for their clinical group. This allowed faculty freedom to individualize meeting times for the clinical seminars and eased on-campus room scheduling. Different types of activities were incorporated to meet students’ cognitive, psychomotor, and affective learning needs. Preplanning activities enhanced organization, and inclusion of varied teaching strategies assisted students to capitalize on their learning styles and enhance their contribution.8 Rather than faculty presenting didactic content or leading patient discussions, they encouraged student ownership of their learning and responsibility to participate in all activities. Although the second-year faculty decided common themes and activities for the clinical seminars such as the IVP practice stations, each had autonomy to implement different methods for accomplishing the clinical seminar goals and focus.

A positive learning atmosphere was established to promote student sharing. A room setup using a round or rectangular table allowed participants to see each other while responding and encouraged meaningful interactions. At the first clinical seminar, faculty specified clear student responsibilities and ground rules such as mandatory attendance, respect for all participants, and active involvement in the activities.2 Faculty with strong facilitation skills more easily assumed dual roles of leading along with participating in the clinical seminar without dominating the discussions. Finally, faculty members had responsibility for engaging learners and maintaining focus yet were flexible and adaptable as unexpected situations arose. For example, when a student encountered a Code Blue emergency for an assigned patient, it was important to debrief the experience in a seminar.

Students were expected to attend all clinical seminars, arrive on time, and come prepared. As stipulated in the course syllabus, all required clinical hours consisted of skills laboratory and simulation activities, clinical seminars, and clinical experiences. Any students missing the mandatory seminars were counseled regarding their absence. Unexcused absences resulted in a plan for improvement. Students were to demonstrate professional skills and values such as being open-minded to new views, critiquing ideas, assuming responsibility for giving and accepting feedback, and maintaining confidentiality about patients and any information shared by their peers.2 Because active involvement was a key component of clinical seminars, students were urged to clarify information or ask questions without being afraid of judgment or reprimand for not knowing the correct answer. Faculty promoted a learning environment by addressing disrespectful students’ behaviors such as snide remarks or “eye-rolling” and instituting corrective action. Students were encouraged to accept each other’s differences while appreciating the importance of everyone’s contribution to the learning process.

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Faculty and Student Feedback

The clinical seminar has now been in place for 5 years. During this time, informal feedback was solicited from faculty and students regarding the positive and negative aspects of the clinical seminars. Throughout each term, second-year faculty debriefed about their individual clinical seminars during monthly team meetings, considering strengths, weakness, and possible revisions. Strengths included less student fatigue and more involvement in learning activities as evidenced by student questions and interactions with their peers. Compared with the traditional postclinical conferences, students demonstrated greater depth of reflection on their clinical practice and application of theory to practice as shown by the quality of the student-led patient discussions. When the clinical seminar guide with identified QSEN competencies was used, students more frequently correlated ways in which the competencies affected their care.

Negative aspects included the amount of time required to develop learning activities and clinical seminar guides. Another factor involved finding suitable seminar times that met the students’ full schedule. One faculty member desired better facilitation and questioning skills. In response, the faculty team offered suggestions and strategies for enriching the seminar discussions. In general, faculty supported the clinical seminar and continued searching for new methods to improve and foster deeper learning.

For the past 2 years at the end of each term’s second and fourth clinical seminars, the author asked for students’ verbal feedback. Depending on the academic term, the number of surveyed students was 8 to 12. Using an informal open format, the author obtained students’ verbal permission to scribe their unnamed comments, regarding what they liked best, what did not work, and any suggestions. If students abstained from sharing their opinions in this format, they were encouraged to submit anonymous comments in writing to the author. Before this process, student comments were obtained on an irregular basis.

On the basis of the collected data, students preferred clinical seminars on campus rather than being scheduled during or after their clinical day because they felt more alert and ready to learn. They liked having time to reflect and process about their clinical nursing education experiences before clinical seminars. The varied activities kept them interested, especially clinical seminars that involved psychomotor skills and problem-solving scenarios. Clinical seminars offered an opportunity to clarify confusing concepts, enhance their critical thinking, and explore ethical concerns. Most felt comfortable sharing with the group. Those students feeling uncomfortable admitted that their uneasiness stemmed from being shy or a “quiet person.” Leading a patient discussion required more work, but most students indicated that it increased their knowledge about their patient.

Some examples of student comments regarding their perceptions of the clinical seminars included “It was scary to present my patient to my peers but I have to admit that it increased my self-confidence.” Learning from peers was confirmed by other students: for example, “At first, I didn’t think I would learn anything from my classmates—but I was wrong. It was good to hear a different perspective from them.” Another student commented on the importance of preparing for seminar: “I liked the weekly focus and application to clinical. Clinical seminar was better when I prepared ahead.” Although students did not provide specific feedback about the QSEN competencies, their application in clinical seminars suggested that students’ knowledge had increased.

Most suggestions for improvement concerned room arrangements, time of day for the clinical seminar, and scheduling during the academic term. Students preferred meeting after didactic class or skills laboratory because they were already on campus. However, students’ least favorite options included meeting after a test and during the last week of the term before final examinations. When possible, faculty scheduled clinical seminars in rooms with tables versus classroom seating to improve interaction and avoided students’ unfavorable scheduling options. Student-led discussion guidelines were revised to give students a clearer focus for their presentation. The guidelines were shared with all second-year faculty to use at their discretion. A few students furnished additional concept ideas such as acid-base imbalance, which were considered for inclusion in the next academic year. To the extent possible, faculty have implemented the suggestions but realized that each clinical group has different perceptions about their educational needs.

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Conclusions

Clinical seminars with deliberate intent and organization can positively affect students’ knowledge, skills, and attitudes regarding the care they provide. Advantages of the clinical seminar include increased student preparation, focused learning that bridges theory and practice, application of QSEN competencies, and promotion of student presentation and leadership skills. The time and energy required to preplan clinical seminars along with coordinating learning activities among multiple faculty and adjuncts can be daunting. Nevertheless, in the evolving clinical nursing education environment, moving beyond traditional approaches to clinical teaching is paramount. The clinical seminar offers 1 approach to retain the values of postclinical conferences yet simultaneously meet the learning needs of 21st-century students.

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References

1. McNelis AM, Fonacier T, McDonald J, Ironside PM. Optimizing prelicensure students’ learning in clinical settings: addressing the lack of clinical sites. Nurs Educ Perspect. 2011;32(1):64–65.
2. Vezeau TM. In defense of clinical conferences in clinical nursing education. Nurse Educ Pract. 2016;16(1):269–273.
3. Nielsen AE, Noone J, Voss H, Mathews LR. Preparing nursing students for the future: an innovative approach to clinical education. Nurse Educ Pract. 2013;13(4):301–309.
4. Sherwood G. Driving forces for quality and safety: changing mindsets to improve health care. In: Sherwood G, Barnsteiner J, eds. Quality and Safety in Nursing. West Sussex, UK: Wiley-Blackwell; 2012:3–21.
5. National Academies of Sciences, Engineering, and Medicine. Assessing Progress on the IOM Report: The Future of Nursing. Washington, DC: The National Academies Press; 2016.
6. Sherwood G. The imperative to transform education to transform practice. In: Sherwood G, Barnsteiner J, eds. Quality and Safety in Nursing. West Sussex, UK: Wiley-Blackwell; 2012:191–209.
7. Megel ME, Nelson AE, Black J, Vogel J, Uphoff M. A comparison of student and faculty perceptions of clinical post-conference learning environment. Nurse Educ Today. 2013;33(5):525–529.
8. Yehle KS, Royal PA. Changing the postclinical conference: new time, new place, new methods equal success. Nurs Educ Perspect. 2010;31(4):256–258.
9. Lim F, Pajarillo EJ. Standardized handoff report form in clinical nursing education: an educational tool for patient safety and quality of care. Nurse Educ Today. 2016;37(3):3–7.
Keywords:

associate degree program; clinical teaching; concept-based curriculum; postclinical conference; Quality and Safety Education for Nurses

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