THE DUALITY OF patient assignments can lead to a breakdown in communication about the expectations of care among faculty, staff, and students. The complexity of multiple caregivers (nursing students and clinical nurses) filling similar roles when caring for one patient may pose challenges. This can lead to omissions in patient care, medication errors, and missed cues about changes in a patient's clinical status.
Clarifying various roles in nursing students' education is imperative to safe and effective patient care. After reviewing the importance of communication, this article outlines practical steps that nursing faculty, clinical nurses, and nursing students can take to improve communication, patient safety, and student learning.
Setting the scene
The Joint Commission included improved communication as one of seven National Patient Safety Goals; the National Council of State Boards of Nursing included communication as one of four fundamental processes used by nurses.1,2 The Institute of Medicine's push for a “culture of safety” and the Quality and Safety Education for Nurses use of teamwork, collaboration, and safety competencies demonstrate the focus on communication and safety in healthcare.3,4
When working as clinical instructors in various hospital units, we recognized gaps in communication among faculty, the nursing students, and nursing staff. We wanted to be proactive in promoting clear and safe communication to ensure patient safety, provide the best possible education for the students, and support clinical nurses who were assisting in clinical education.
We initially believed we were meeting the need for communication by providing the clinical agency with the learning objectives, dates, and times of student clinical experiences. However, we made some assumptions, such as that clinical nurses would be prepared to take on the role of nurse preceptor. McCarthy and Murphy noted that nurses who'd attended a 2-day formal workshop about how to teach and assess nursing students still didn't feel well prepared for the preceptor role.5 Not all clinical nurses with whom we collaborate in clinical learning have formal training in educating students.
We also assumed that staff would be aware of student, faculty, and preceptor roles and expectations. Even nurses familiar with the preceptor role didn't necessarily understand the difference between precepting a student and precepting a new grad or new employee.
Clinical nurses bring many gifts to the clinical learning environment, including clinical expertise and the ability to act as a role model, instruct, and supervise nursing students.6 Florence Nightingale herself insisted that nurses be trained in the hospital by practicing nurses who were “trained to train.”7 But many clinical nurses are expected to take on the role of preceptor, role model, or mentor with little advance preparation, adjustment in workload, or recognition. Because students have limited clinical knowledge and may have difficulty extracting the important cues from a clinical situation, clinical nurses and clinical faculty must be able to clearly communicate to guide student decision making.
Patient care and student education are roles shared by clinical faculty and clinical nurses. Each nurse needs to assume responsibility for his or her part in safe patient care in addition to being aware of the other stakeholders' roles. (See Sorting out roles and responsibilities.) Open and respectful lines of communication are essential.
For faculty. To better meet the needs of the nursing staff and students, we developed a student skills checklist, which highlights the skills that may be performed by the student independently and those that must be performed with faculty/staff observation. (See Student skills inventory for clinical staff.)
Because we've found that many students feel timid and unsure of how to communicate clearly with experienced practitioners, we encourage the students to use the information on this form to “break the ice” with staff.
Having clinical faculty present in the clinical unit also helps to build relationships and provide interaction with busy clinical nurses. These nurses can be overwhelmed when they realize that they'll have to “take care of” a student, especially if their workload isn't adjusted for the time and effort it takes to teach a student. When faculty participate as active team members, clinical nurses' commitment to participating in student learning increases. Faculty joined team huddles on each unit at the beginning of the shift to communicate student assignments, learning objectives, and other pertinent information, such as negotiation of care and responsibilities such as medication administration or personal care.
Before the beginning of the semester, a brief face-to-face meeting can help to open lines of communication, clarify student-learning needs, and validate faculty need for staff. We also used unit meeting time and preceptor forums to help clarify roles and expectations before the clinical experience.
For clinical nurses. An easy way to open the flow of communication is to welcome students to the unit and inquire about personal learning goals or clinical learning objectives. Be inquisitive: Start a dialog with students and faculty. Be sure to have a discussion with faculty to verify or clarify the division of labor, such as who will supervise students who are administering medications or changing dressings.
Students have difficulty appreciating the amount and extent of critical thinking that occurs in the clinical setting. For example, when faculty questioned a student preparing for medication administration, the student noted, “I didn't realize medication administration involved this much thinking. I thought it was just, ‘Here are your pills.’” Be an active and explicit role model to students by thinking out loud and demonstrating to students how to move through the clinical decision making, care planning, and critical thinking processes.
For faculty and staff. Because learning is enhanced by self-assessment, guiding students in performance evaluation can help to facilitate critical thinking. The hard part is guiding students in that reflection and in the discovery of those “Ah ha!” moments.
Asking specific questions enhances reflection. For example, after a student gives an I.M. injection for the first time, the instructor can ask: “How did you feel? How did your verbal or nonverbal communication convey this feeling? How do you suppose your patient felt about that?” Immediate structured reflection lets students develop self-awareness and the opportunity to learn important skills for future practice. Reflection can also help instructors understand a student's line of thinking and clarify any misconceptions.
Be sure to close the communication loop about student performance because feedback is needed for the student's future growth and learning. Provide feedback in a way that encourages receptivity. Providing constructive feedback (which many perceive as negative feedback) can be difficult, but we've found the “sandwich cookie” approach works well: surround the constructive feedback on either side with positive feedback.
Clinical instructors and clinical nurses need to overcome obstacles to providing constructive feedback to improve patient safety, which is a responsibility shared by clinical nurses, students, and faculty. Without constructive feedback, students can't fully recognize their learning needs or achieve desired learning goals.
Nurses and clinical faculty should feel free to provide positive feedback. Students and faculty need to know what went well on the unit so that areas of strength can be used most effectively in the future. We need to build students' confidence because they'll be our colleagues in the future.
Finally, faculty and staff should establish professional working relationships with each other to help close the communication loop. We find many clinical nurses are reluctant to provide what's perceived as negative feedback about a student performance. Communicating areas of weakness to students and faculty doesn't mean they'll receive a failing grade; instead, doing so helps nursing faculty plan future learning experiences to develop those areas into strengths. This type of communication is important because faculty may be supervising eight or more students and can't possibly be with all students at all times. Clinical nurses' observations of students' clinical performance should be used to guide students throughout various clinical experiences. Feedback is paramount to developing safe, competent practitioners.
This clear communication of student performance also allows the faculty to weigh the patients' care needs and the students' learning needs. For example, although the plan of care may promise a great learning experience for a student, the staff may be aware of some sensitive patient needs that may necessitate avoiding the assignment or providing some additional guidance for the student. On the flip side, a patient may not need many clinical nursing “skills” (perceived by students as the important skills associated with I.V.s and nasogastric tubes, for example), but the clinical nurse may be aware of a patient who requires some additional psychosocial support.
Another method of building relationships is including faculty and students in the unit's workflow. Share staffing, workload, or patient concerns with faculty and students to leverage them as an asset rather than a liability in the unit workflow. For example, clinical nurses might share that a patient has complex emotional needs and may not be appropriate for a student assignment. However, with faculty probing and faculty and staff support for the student, she or he may be able to provide the extra care this patient needs. A challenging assignment for students may become a positive learning experience with the extra coaching provided by both faculty and staff. This approach can also ease some of the demands on the staff.
Information that clinical nurses share with faculty can be used in preclinical briefings or huddles, which may be a useful venue for collaborative problem solving and mutual meeting of needs. These briefings also help students to become more aware of overall unit needs and how to address these needs in their own workflow.
Clinical nurses can share their suggestions for improvement with the faculty. With the valuable input of their staff counterparts, faculty can make personal practice or curricular changes that will better prepare students, maintain a safe environment for patients, and improve relations with clinical nurses. Because the goal of faculty is to prepare students for the workforce, the feedback of the current workforce is essential in planning educational opportunities and preparing students.
Our goal in changing the way in which we approached clinical learning was to improve the quality of the experience for the stakeholders: to maintain safety for patients, improve learning opportunities for students, minimize stress to the nursing staff, and improve faculty's ability to facilitate a positive learning environment for all stakeholders. Clarifying student, staff, and faculty roles and expectations increased the collaboration among the stakeholders and fostered mutual trust and open communication. These improved lines of communication are imperative to maintaining a safe patient care environment and high-quality clinical nursing education.
Student skills inventory for clinical staff
Nursing student: _______________________________
Thank you for working with the nursing students. Your knowledge and expertise will enhance the student's learning experience immensely.
At the completion of this clinical experience, the student should be able to:
- Discuss the special needs and nursing management of this unit's patient population.
- Demonstrate the ability to individualize age-specific and culturally directed patient care.
- Assess patients and carry out necessary interventions that will promote recovery and prevent complications.
- Demonstrate professional behavior while interacting with other healthcare professionals.
- Provide educational support for patients experiencing alterations in their quality of life.
- Know the action, adverse effects, dosage, and purpose of medications frequently prescribed for patients in the unit and how drug effectiveness is measured.
- Administer medications with the instructor after passing the medication administration exam.
- Identify pertinent information necessary for discharge planning, formulate discharge goals, and utilize the nursing process to arrive at desired outcomes.
- Communicate pertinent patient data to faculty and staff.
- Identify ethical dilemmas.
- Demonstrate technical skills unique to the specific patient care unit.
Individual skill set for students:
- Vital signs (VS)
- Intake/Output (I/O)
- Head-to-toe assessment (please verify student's assessment findings)
- Documentation (VS, I/O, and assessment/care)
- Patient activities of daily living
- Application of thromboembolism deterrents (intermittent pneumatic compression devices and graduated compression stockings)
- Simple dressing changes
- Discontinuation of urinary catheters
- Collection of lab specimens (instructions must be verified with student by clinical RN or nursing faculty)
- Medication administration (only with nursing faculty):
- – P.O. medications
- – Subcutaneous medications (not insulin)
- – I.M. medications
- – I.V. fluids
- – Insulin (after diabetes class)
- – I.V. piggyback and I.V.-push medications
- – Patient-controlled analgesia
- Point-of-care glucose monitoring (with clinical RN)
- Removal of short peripheral I.V. catheters
- Peripherally inserted central catheter and central venous access device site care (should be completed with RN or nursing faculty)
- Chest tube site care (should be completed with clinical RN or nursing faculty)
- Insertion of nasogastric tube (should be completed with clinical RN or nursing faculty)
- Complex dressing changes (should be completed with clinical RN or nursing faculty)
- Patient/family education (should be completed with clinical RN or nursing faculty)
Adapted and reprinted with permission from the Department of Nursing at Luther College, Decorah, Iowa.