We must strengthen clinical nursing education!

By Connie Bowler | 08/22/2019

Real-life settings validate classroom- and simulation-based teaching.

We must strengthen clinical nursing education!
Despite recent classroom reforms and simulation, experiential learning in clinical settings is still the bedrock of nursing education, writes the author.

Connie BowlerTo meet the demands of a complex and changing healthcare environment, nurse educators are being challenged to transform nursing education. We’re asked to prepare nurses of tomorrow with a broad set of skills that include sound knowledge, advanced thinking, ability to make accurate judgments, technical proficiency, flexibility, professionalism, and impeccable ethics. All of these are to be evident while supporting—in dynamic situations—the emotional and social needs of patients.

This is a tall order! Thoughtful planning and preparation are needed to design and build quality nursing education programs. To meet the demand for nurses and expand programs, we need exceptional talent in the classroom, in labs, and at the bedside. As a nurse educator, I embrace this mission.

We talk about the importance of providing students with a solid foundation of knowledge, skills, and patterns of thinking and problem-solving that translate effectively into practice. It’s a process and, as any good builder knows, expert craftsmanship is essential. The same is true for nurse educators. To prepare future nurses, we need experts with knowledge and clinical skills who are able to proficiently communicate, facilitate, and instruct.

Reformed classrooms
As a nurse educator, I have witnessed the transformative changes that have taken place recently in nursing programs. In the classroom, schools have reformatted course content to teach broad concepts, using examples to illustrate desired patterns in problem recognition, thinking, and acting. Students are required to come to class prepared to discuss content instead of merely receiving it. We see less sitting and getting in the classroom and more application and engagement. Collaborative, small-group learning to stimulate discussion and critical thinking has been incorporated with positive results.

These and other changes have made it necessary for classroom educators to retool their teaching skills and adopt new methods of instruction for effective learning, and students’ foundational nursing knowledge has been strengthened as a result. Throughout this process, nursing programs have supported educators with continuing education, consultation, and research.

Technology
Simulation has also been a critical component in building nursing students’ foundational knowledge and skills. Educators now have an array of technology available to reproduce clinical situations in a controlled environment and safely determine how students respond. Simulation allows educators to observe student reactions over time, enabling teachers to provide feedback and discuss where improvements need to be made. Nursing schools have invested significant time, money, and energy in this technology and in educating the educators who utilize it. In a relatively short time, simulation has become a cornerstone in most nurse education programs.

Despite classroom reforms and increased use of technology, experiential learning opportunities found only in clinical settings are still the bedrock of nursing education. Only in authentic, real-life settings can nurse educators truly validate the success of classroom- and simulation-based teaching and test the soundness of the educational foundation they have built.

Clinical critical
Clinical experiences provide students with the opportunity to apply the theory, skills, thinking and reasoning competencies, and evidence-based practices they have learned in the classroom and simulation lab while caring for real patients. This experiential learning environment also provides educators with insight into student acquisition of the cultural norms of nursing and their ability to relate interprofessionally with other healthcare personnel.

Providing authentic, high-quality clinical learning opportunities for students is critical, which is why nursing schools devote considerable time to securing and keeping clinical sites. As more educational institutions inaugurate or expand nursing programs, this effort becomes increasingly competitive.

Quality clinical experiences require quality clinical instructors who are skilled in their craft. Excellent teachers know how to bring about the best learning opportunities for students and are key to providing a rich and robust experience. Because nursing schools require a large number of clinical instructors, that’s where many nursing educators begin their careers, often part time.

While all of them should be competent—if not expert—in their clinical skills, many come to the role as beginners.

Typically assigned to off-campus locations where they have little access to educational resources and mentors, these novice educators are responsible for taking a small group of inexperienced students into unpredictable patient settings and providing quality nursing care. There we rely on them to instruct, assess, and evaluate student performance; provide meaningful feedback; and address performance or professional issues—all while serving as the nursing program’s liaison at the clinical site. I worry that these expectations exceed their preparation.

Overlooked and underdeveloped
I believe that strengthening the educational competencies of clinical instructors early in their teaching careers is an area that has been overlooked and underdeveloped. Strengthening the ability of clinical educators to teach effectively is imperative to their success and that of their students.

It begins with the selection and hiring process. Hiring clinical instructors is based primarily on their clinical experience and expertise—essential criteria, to be sure—but it’s also important to identify their views on clinical education. Because many new instructors replicate their own learning experience, it’s imperative to understand what that experience was and whether or not it was effective. Do candidates’ beliefs about nursing align with those of the nursing program? These questions are often absent from the interview process. Besides the obvious clinical importance of knowing what candidates believe about nursing, awareness of those beliefs can help create effective orientation programs if they are hired.

Nursing schools are typically required by state law to provide orientation for clinical instructors, but how they respond to that mandate varies tremendously. Orientation programs range from self-directed reviews of policies, laws, and rules to formalized mentored sessions with experienced instructors. (Clinical site competencies and requirements will also need to be completed.) Ideally, all nursing programs should invest in a formal approach.

Orientation leaders should begin by outlining course goals and identifying clinical objectives that give prospective clinical instructors a clear understanding of expected outcomes. The current performance level of the nurses undergoing orientation should be discussed, and they should be instructed about what constitutes success and failure in the clinical setting. They also need to know strategies that promote competence and learning in that setting.

Interpersonal skills imperative
Clinical instructors influence student attitude, professionalism, and cultural competence, so they must be able to provide feedback that promotes student growth without diminishing self-esteem. In addition to developing coaching and group dynamic skills, they need to become proficient in mediating student and clinical site issues. Interpersonal skills are imperative.

It’s also important for clinical instructors to understand their role as program ambassadors at the clinical site as their actions can either strengthen a school’s reputation—critical to maintaining clinical placements—or diminish it.

Finally, clinical instructors can increase their effectiveness by developing their ability to ask questions that probe, seek understanding, and reveal thinking and reasoning without being intimidating or “gotcha” in nature. The ability to guide conversations that promote student reflection and tie nursing concepts to the clinical experience is essential to achieving desired learning outcomes. These skills can be learned through education and mentoring. We should constantly strive to enhance the ability of clinical instructors to provide feedback that is constructive and meaningful and inspires growth.

Transforming nursing education programs to meet current and future healthcare needs requires that clinical instructors be at the top of our list for professional development. Their contribution to educating future nurses is as significant as that of classroom, simulation, or laboratory educators. We must not overlook the importance and impact of preparing these instructors to do the enormous task they’ve been assigned. To invest in their development is to invest in our students and our nursing programs. Clinical instructors strengthen the educational foundation that is built in classrooms and learning labs and are critical to our success. RNL

Connie Bowler, DNP, RN, is program director, Nursing Department, Lakeland Community College, Kirtland, Ohio, USA.

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