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Department: LEARNING CURVE

Supporting students in their first clinical experience

D'alesandro, Maryann DNP, MSN, RN, CNOR, BC

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doi: 10.1097/01.NURSE.0000769852.36733.a6
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LEARNING SKILLS, from the simple to the complex, is challenging at times. However, mastering clinical skills is very satisfying. As simple as it may sound, clinical instructors and nurses should remember this when working with nursing students who are in their first clinical experience. This article discusses some of the challenges and perspectives of clinical instructors and nursing students in their first clinical experience, with recommendations to support and promote a positive experience.

A make-or-break component

Clinical experiences are a fundamental and essential component of prelicensure nursing programs. The three key people involved in a student's clinical experience are the student's clinical instructor, the facility clinical nurse whom the student will be assigned to for their clinical experience, and the student themselves.

Nursing students typically attend clinical in the second term of their nursing program, with the first semester consisting of didactic courses and lab skills only. These first semester courses are dedicated to the theory behind key skills, such as hand hygiene, sterile technique, vital sign measurement, and physical assessment. The first semester includes applying prerequisites to fundamental nursing courses, such as pathophysiology and health assessment. Additionally, first-semester students will begin to build the foundations of critical thinking and theoretical knowledge in nursing practice that help to develop clinical judgment. Although most nursing programs use simulation (low, medium, or high) to prepare the student for patient care and clinical judgment, it is still a mannequin and not a real person. Clinical experiences offer students the first opportunity to apply what they learned in labs and classes in the clinical environment.

It should not be surprising for students to feel a range of emotions, such as fear, anxiety, apprehension, and excitement, when they initially arrive on the clinical floor.1 The first experiences in the clinical environment can have an impact on their practice and may even affect their decision to become a nurse.2

Nursing student perspectives

Nursing students often are afraid to make a mistake—and possibly hurt someone—in their first clinical experience. Reassure students they will not be doing any invasive procedures or interventions that could cause harm in the first few weeks. Explain scaffolding of clinical responsibilities and each week they will take on different or more advanced assignments. Others may verbalize their fears of getting lost on a unit or in the hospital, academic/clinical failure, being put on the spot or being embarrassed if they do not know the answer, and not knowing where everything is if they are asked to retrieve an item.1,2

Nursing instructor perspectives

Although a unit orientation in which students are assigned individually or in pairs can be used, an orientation involving the entire clinical group is more effective. It allows for greater understanding and the opportunity to ask questions.3 Discussing the equipment or supplies satisfies the “why” questions they may have and assists the students in clinical judgment and critical thinking. Asking an important question such as, “What do you do to the code cart before responding to a code with it?” promotes the use of critical and common-sense thinking needed as an RN. Making sure that it is unplugged and fully stocked first promotes a higher level of thinking.

Student feedback

Several studies have been conducted to understand the stressors behind a nursing students' clinical experience.1,2 Areas that contribute to these stressors included students being embarrassed by the clinical instructor or nurse in front of the patient and/or patient's family; students being rushed to complete a procedure or medication administration without proper knowledge of it; clinical instructors who cram too much information into a clinical day; students having unclear or excessive expectations of workload above their capacity; and staff using nursing students to reduce staff workload.2,4

Some of these experiences may cause intense emotions, feelings of helplessness, and emotional exhaustion.1,2 Students reported that they sometimes cannot stop thinking about difficult or stressful clinical experiences. It consumes them, and they have a hard time trying to come to terms with certain situations. This is more common when faced with an ethical or moral experience in clinical.1 Therefore, it is important to communicate with nursing staff the constraints of students and to not automatically think they are purposely not doing something or are being lazy.

Heidari and Norouzadeh found a gap between the clinical nurse's expectations and what was taught in the classroom and nursing lab.5 For example, inserting an indwelling urinary catheter and obtaining peripheral venous access are taught and assessed in the nursing lab. However, due to hospital policy around approved nursing student skills, they may be unable to perform these skills in the clinical setting. The reasoning behind this may be a response to the denial of insurance reimbursement due to catheter-associated urinary tract infection and I.V. insertion injury, lack of patient approval for a student to perform these skills, nursing program restrictions, or the like. Therefore, a list of approved clinical skills and experiences with clear definitions of expected student participation is important for the student, clinical nurse, and patient safety. Students indicated just wanting to do a good job and impressing their clinical instructor and peers. Students may become withdrawn due to information and sensory overload; becoming very emotional over patient situations involving a poor prognosis or a patient death; feeling intimidated; and competing with their peers for experiences and assignments.1,2

Supporting first-time students

Knowing what students value can provide insight on support strategies. According to Reising et al., positive characteristics that can support a student's success include consistency, organization, patience, punctuality, and good communication skills.6 The study also found that students value an objective and fair evaluation, feeling encouraged to ask questions, professional feedback, feeling that their instructor and clinical nurse are approachable, and that the instructor and the clinical nurse are knowledgeable. Begin by welcoming students on the clinical unit and introducing them to the nursing and ancillary staff. Articulating clear expectations may decrease student confusion and provide stability and consistency.

Accessibility and approachability are important to the nursing student's experience, as this provides an open line of communication. Discuss challenges in private and provide constructive feedback. These support strategies promote a collaborative and cooperative learning environment needed for student success.

In their conversations with first-semester nursing students, Reljic et al. found that walking students through what a clinical day looks like prior to their first clinical experience could be helpful.4 Interviewed students suggested briefing students on the following:

  • how to discuss patient assignments without violating patient privacy
  • discussing preconferences, observations, and break and lunch schedules
  • how to find their clinical nurse and listen to report
  • how to plan the day
  • expected patient care
  • how to communicate patient concerns to the clinical instructor or nurse
  • how to contact the clinical instructor in case of emergency
  • postconference expectations.4

One area that may be overlooked is grief debriefing. Students experiencing the death of a patient for the first time or assimilating it to a personal experience will need support, patience, and understanding. It is important to set time aside to do a grief debrief by letting the student feel emotions, verbalize feelings, and process the loss. Simply taking a student aside in a private area after a stressful experience or just checking on them will have a positive impact on that student.

Clinical workshop

Students often fear the unknown. Some students may have had little or no patient contact or have never been in a hospital before. Some may have never had exposure to disease (acute or chronic) or death. Only until their first clinical experience are some students seeing, experiencing, and taking care of patients with illness.

A clinical workshop is one support initiative that can alleviate fear of the unknown. A clinical workshop is a dedicated class session discussing what to expect and what is expected of students. Attending students should receive a folder with important information such as the facility name with parking directions and when and where to meet on the first day; length of clinical day; hygiene and dress expectations; what students can bring, such as a mobile phone, stethoscope, watch with a second hand, lunch, small notebook, pen/pencil, and more; and whether students should limit personal items due to a lack of secure storage areas. Other important information that should be discussed is the preferred and expected method of contacting and communicating with the clinical instructor, both during clinical and in the event that the student will be late or absent.

On the first day, additional information to communicate with students should include an overview of the unit, types of patients, flow (busy or slow), technicians and their responsibilities (if applicable), and other experiences they may observe or be exposed to. Be specific regarding due dates and times and provide examples of what is expected of clinical assignments, including patient assignments, postclinical care planning, and self-reflections.

Depending upon the facility, the retrieval of patient assignments the day before or day of clinical may vary. Some facilities only allow students to obtain assignments during a slower time period that will not interfere with patient care and access to medical records. It is important to show students the location of posted assignments on the unit as well as the procedure if a patient is discharged or transferred, the patient does not want a student, the student cannot access the medical record (paper or electronic), or the student cannot access the unit due to lockdown or access restrictions. Another aspect to consider is the expected dress code for obtaining patient assignments. Be specific and confirm facility expectations as clinical students are viewed as guests. A good practice is to include the instructor's mobile number on the patient assignment sheet if any challenges arise. Also, have a plan in place in case of “what ifs” to eliminate numerous phone calls, including a list of additional patients that a student can choose from if their assigned patient is not available.

Discussion

Clinical instructors and nurses should foster a trusting relationship with the student that provides guidance, emotional, and learning support.3 Experienced clinical instructors and nurses have a responsibility to educate future nurses and provide them with the experience, knowledge, and skills required to become a caring, patient-centered, and skilled nurse. It is important to identify stressors early to assist nursing students to the clinical environment with strategies to set them up for success.

REFERENCES

1. Mirlashari J, Warnock F, Jahanbani J. The experiences of undergraduate nursing students and self-reflective accounts of first clinical rotation in pediatric oncology. Nurse Educ Pract. 2017;25:22–28.
2. Alshahrani Y, Cusack L, Rasmussen P. Undergraduate nursing students' strategies for coping with their first clinical placement: descriptive survey study. Nurse Educ Today. 2018;69:104–108.
3. Kol E, Ince S. Determining the opinions of the first-year nursing students about clinical practice and clinical educators. Nurse Educ Pract. 2018;31:35–40.
4. Reljic NM, Pajnkihar M, Fekonja Z. Self-reflection during first clinical practice: the experiences of nursing students. Nurse Educ Today. 2018;72:61–66.
5. Heidari MR, Norouzadeh R. Nursing students' perspectives on clinical education. J Adv Med Educ Prof. 2015;3(1):39–43.
6. Reising DL, James B, Morse B. Student perceptions of clinical instructor characteristics affecting clinical experiences. Nurs Educ Perspect. 2018;39(1):4–9.
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