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Best Practices in Clinical Teaching and EvaluationMarilyn H. Oermann, PhD, RN, ANEF, FAANThelma M. Ingles Professor of NursingDirector of Evaluation and Educational ResearchDuke University School of NursingEditor, Nurse Educator & Journal of Nursing Care Quality [email protected]
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Challenges in Clinical Teaching⦿ Faculty shortages
⦿ Complex practice environments◼ Increased complexity and acuity◼ New technologies, highly specialized
interventions◼ Focus on quality and safety◼ Restrictions by clinical settings
etc
.
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Challenges in Clinical Teaching contLack of evidence to guide clinical education practices
Who uses?
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Challenges in Clinical Teaching cont
⦿ Traditional model of clinical teaching◼ Clinical learning dependent on:
• Available patients and experiences
• When students “there”
◼ Research findings: graduates not well prepared
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Challenges in Clinical Teaching cont⦿ National survey by Nursing Executive
Center of new graduates’ proficiency in 36 competencies◼ Only 10% of nurse executives report new
graduates prepared for practice◼ Satisfied with only 2 competencies:
• Use of information technology (e.g., computers)• Developing rapport with patients
Berkow S et al. Assessing new graduate nurse performance. J Nurs Adm. 2008;38(11):468-474.
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Challenges in Clinical Teaching cont
⦿ Lowest ranked competencies: learned in clinical setting◼ Work independently◼ Manage multiple
responsibilities◼ Prioritize◼ Anticipate risks◼ Delegate
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Challenges in Clinical Teaching cont
⦿ Systematic review of experienced RNs’ perceptions of clinical competence of new graduates▪ 2 main areas of concern related to critical
thinking and clinical/technical skills
Missen et al. Registered nurses' perceptions of new nursing graduates' clinical competence: A systematic integrative review. Nurs Health Sci.2015 Nov 23. doi: 10.1111/nhs.12249. [Epub ahead of print]
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Rethink Clinical Education⦿ New models of clinical education◼ Dedicated education units◼ Clinical immersion experiences◼ Focused clinical teaching
⦿ Clinical teaching◼ Use of evidence◼ Integrative cases◼ Assignments geared to course outcomes
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Dedicated Education Unit (DEU) Model
⦿ Partnership between school of nursing and health care agency
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DEU Model cont ⦿ Traditional
⦿ DEU
Preceptors, clinicians are
teachers
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Capstone Course ⦿ Preceptor model
More students in agency
⦿ DEU model
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Clinical Immersion Experiences⦿ Capstone (transition) courses⦿ Multi-method study◼ Enhanced competence in nursing role◼ Graduates often seek employment and
remain at capstone site or within capstone specialty◼ No effects on achievement exams or
NCLEX-RN pass rates
Rebeschi L, Aronson B. Assessment of nursing student's learning outcomes and employment choice after the implementation of a senior capstone course. Int J Nurs Educ Scholarsh.2009;6:Article21.
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Education-Service Partnerships⦿ Educating students and staff⦿ Addressing workforce issues◼Majority of current partnerships focus on
building workforce capacity (solving problems of lack of clinical faculty and clinical placements )
⦿ Improving opportunities for staff to advance their education
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Education-Service Partnerships cont⦿ Advancing research and evidence-
based practice◼ Faculty access to subjects for research◼ Clinician access to research experts◼ Opportunities for faculty clinical
scholarship
Beal JA. Academic-service partnerships in nursing: an integrative review. Nurs Res Practice. 2012;Article ID 501564. Duffy JR et al. Nurses' research capacity and use of evidence in acute care: baseline findings from a partnership study. J Nurs Adm. 2015;45(3):158-164.
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Focused Clinical Teaching
⦿ Focus on specific competencies tobe developed
⦿ Provide experiences in “total patient care”, but learning activities may not involve complete care◼ Activities to learn clinical concepts (e.g.,
immobility)• Experience concept in simulation, then clinical
practice
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Focused Clinical Teaching cont⦿ Better studies on outcomes of different
models and teaching methods⦿ Study (ADN program) comparing 1 long
day (12 hours) vs. 2 short days for clinical experience◼ 146 students randomly assigned◼ No difference in learning outcomes between
the 2 groups
Danner M. Comparison of 1 long versus 2 shorter clinical days on clinical learning outcomes of nursing students. Nurse Educ. 2014; 39(6):280-284.
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What evidence supports our clinical teaching methods in nursing?
Evidence-based Clinical Teaching
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Qualities of Effective Teacher
⦿ Well studied⦿ Good teaching◼ Interactional process
• Educator-learner and collaboration among learners
• Qualitative studies
◼ Prompt feedback
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⦿ Most important variable affecting learning
⦿ Should be:◼ Specific, informational◼ Given at time of learning ◼ For procedures, technologies, and motor
skills, provide both verbal and visual feedback
Feedback
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⦿ Deliberate practice◼ Repetitive practice of skills (cognitive,
motor)◼ Assessment of performance + feedback
⦿ Strong association between extent of practice and performance
⦿ Loss of skill with non use⦿ Distribute practice over time
Practice
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Motor Learning and Practice
Cognitive
• Understanding how to perform skill• Accuracy
Associative
• Refining movement• More consistency
Autonomous
• Can perform without thinking about each step
• Automatic
Practice
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Cognitive Phase⦿ When skill first introduced⦿ Student learns cognitively◼What the specific skill involves◼ How to perform the skill (equipment,
technique)
⦿ Verbal reminders from teacher prompt performance
⦿ Performance: slow, awkward with goal to perform accurately
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Associative Phase⦿ Focus is on refining the skill◼Master smaller details (e.g., timing)
⦿ Performance becomes more consistent
⦿ Practice can lead to rapid improvement in performance
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Autonomous Phase⦿ Proficient in performing skill⦿ Performance automatic◼ Little or no cognitive activity
⦿ Improvement in performance is not as obvious ◼ Able to adapt motor skill, procedure to
unique patient situation and environment
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Practice is Critical
⦿ Skill learning requires practice⦿ Without practice, psychomotor and
clinical skills cannot be learned and maintained
⦿ Goal: learn to perform skills without guidance◼ Adapt them to varied clinical situations
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Student Stress in Clinical Practice⦿ Clinical practice most stressful experience◼ Fear of making mistakes
◼ Feelings of incompetence
◼ Interactions with others (inverse relationship to stress)
◼ Being evaluated…
Hensel D, Laux M. Longitudinal study of stress, self-care, and professional identity among nursing students. Nurse Educ.2014; 39(5):227-231.
Alzayyat A, Al-Gamal E. A review of the literature regarding stress among nursing students during their clinical education. Int Nurs Rev. 2014; 61(3):406-415.
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Student Stress in Clinical cont⦿ Teach stress
management◼ Research: need to
practice techniques
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Teacher Stress in Clinical Teaching⦿ Multiple demands⦿ Heavy workload⦿ Balancing needs of students,
patients, staff⦿ Teaching inadequately prepared
students…
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Clinical Teaching Methods
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Patient Assignment⦿ Choose variety of clinical learning
activities◼ Few studies◼ Patient care, but not all “complete care”◼ Other activities
Focused on clinical competencies of course and students’ learning needs
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Clinical Learning Activities
⦿ Designed to promote attainment of specific competencies
⦿ Use in place of or in addition to patient assignment
⦿ Better coordination with simulation
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Prelab Learning Activities: Too Many?⦿ Majority of students (n = 208, 74%)
complete prelab activities on day before clinical◼ Only 10 (4%) directly before clinical
⦿ Students spend fair amount of time on prelab activities◼ 50% (n = 142) spent 60 to 90 minutes
collecting information at clinical site◼ Additional 13% (n = 40) spent more than
90 minutes
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Prelab Learning Activities: Too Many? cont⦿ Prelab paperwork outside of clinical
practice◼ 14% (n = 41) spent less than 60 minutes◼ 38% (n = 112) spent more than 120
minutes ◼ Taken together, many students spent up
to 5 hours on prelab activities
Turner L, Keeler C. Should we prelab? A student-centered look at the time-honored tradition of prelab in clinical nursing education. Nurse Educ.2015;40(2):91-95.
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Asking Questions
⦿ What do studies show? ◼ Levels of questions
• Teachers and preceptors ask low level questions in clinical practice, conferences
• Many questions seek yes/no response
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Short Integrative Cases & Unfolding Cases
⦿ Why use?◼ Integrate knowledge, values, practice◼ Link to practice ◼ Think about clinical situations not
encountered in prior practice but need to know◼ Promote higher level thinking
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Sample CaseA patient is transferred to your unit from a community hospital with headache, nausea, and vomiting. The patient’s headache is getting progressively worse, and she is losing vision in her right eye.
1. What data are most important and why?2. What are the next steps? Provide rationale. 3. Prepare a report for handoff.
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Cases: What are Outcomes?⦿ BEME review of case-based learning◼ 104 studies◼Majority (61%) with single cohorts◼ Outcomes
• Students and teachers enjoy, think enhances learning
• Evidence unclear as to effects on learning
Thistlethwaite JE, et al. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teacher.2012;34:e421-e444.
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Written Assignments in Clinical Courses⦿ Goals for each assignment?⦿ How much repetition?⦿ Short assignments:◼ Prevent summarizing what others have
written◼ Focus on outcomes◼ Can be done in clinical conferences and
critiqued by peers
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Examples⦿ Describe how your patient’s
treatments and interventions are similar to or different from your readings and why. (1 p.)
⦿ Select a new intervention for your patient and develop a rationale for its effectiveness. (1 p.)
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Try Group Writing in Post Conference
Too Much to Do?Too Many Papers? Not Enough Time?
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Clinical Conferences⦿ What is goal? ⦿ Limited studies◼ Some compare face-to-face to online post
clinical conferences◼ Active learning strategies
15 minutes
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Clinical Conferences
⦿ Gear questions to competencies/ outcomes
⦿ Ask higher level questions to assess thinking
⦿ Formative evaluation
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Clinical Conferences cont⦿ Discussion of assessment ◼ What data are important? Not significant?◼ What data are missing to arrive at the
diagnosis/problem?
⦿ Critique of interventions◼ As a group generate other possible
interventions, or◼ Individually list other interventions, pass to
next person to critique
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Concept Maps⦿ Studies in nursing:◼ Effective for problem solving and critical
thinking • Varied measures of critical thinking
◼ Guidelines for use? Timing in course and clinical experience? How many?
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Concept Maps⦿ Other studies◼ Concept maps:
• Promote meaningful learning
• Are additional resource for learning
• Useful to provide feedback to students
• Assess learning and performance
Daley BJ, Torre DM. Concept maps in medical education: an analytical literature review. Med Educ. 2010;44(5):440-448.
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Clinical Evaluation
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Purposes of Clinical Evaluation⦿ Identify existing competencies⦿ Identify learning needs to be
addressed during clinical practicum⦿ Assess progress⦿ Make judgments if competencies
achieved at end
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Concept of Clinical Evaluation⦿ Involves observing performance and
judging student’s competence ⦿ Subjective process◼ Judgment influences what is observed
and interpretations◼ Key is fairness—judge all students by
same standards
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Clinical Evaluation vs. Grading⦿ Evaluation◼ Teacher observes performance and
collects other types of data, then compares information to standards to make a judgment
⦿ Grading◼ Assigning a symbol to represent the
judgment made
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Formative vs. Summative⦿ Formative ◼ Feedback, progress ◼ Not graded
⦿ Summative◼ Achievement of outcomes, competencies◼ End-of-instruction◼ Graded
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Clinical Evaluation: Essential Steps⦿ Decisions: 1. Purpose of evaluation?2. Formative or summative?3. Grading (P-F, letter, other)?4. Evaluators◼ Faculty only? Preceptor? Self? Multiple?
5. What methods for evaluating each competency?
6. How many times?
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Predominant Methods1. Observation◼ Of competencies to be achieved ◼ Consider
• Student’s level of expertise
• Effects of clinical situation on evaluation
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Observation: Studies show…⦿ Your values and biases ◼ Over-reliance on 1st impressions
⦿ Window of time
⦿ “Good data” but incorrect judgment
So…
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Predominant Methods cont2. Rating performance◼ List of outcomes or competencies learner
is to demonstrate◼ Scale for rating performance of them◼Most are intended for summative
evaluation
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Areas Addressed by Competencies ⦿ Concepts, theories, and other knowledge
for clinical practice⦿ Use of evidence in practice⦿ Assessment, diagnosis, plan,
interventions, and evaluation of outcomes⦿ Psychomotor and technological skills,
other types of interventions, and informatics competencies
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Areas Addressed by Competencies cont⦿ Values related to patient care⦿ Communication and skill in collaboration⦿ Quality and safety⦿ Leadership and role behaviors⦿ Accountability and responsibility⦿ Self-development and continued learning
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Types of Rating Scales⦿ Pass-fail most common⦿ Letter system⦿ Qualitative labels (excellent to poor)⦿ Frequency labels (always to never)⦿ Matrix combining different qualities
of the performance
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Clinical Evaluation Tool should be:1. Consistent with outcomes or
competencies2. Valid◼ Does tool collect intended information
about performance?
◼ Does tool measure safe, effective practice?
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Clinical Evaluation Tool should be: cont3. Reliable◼ Same results when used by different
faculty and with different student groups?
4. Appropriate number of competencies?
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Clinical Evaluation Tool ⦿ Same tool for all courses or course-
specific tool?◼Most use 1 tool for all courses◼ Competencies adapted to each course
⦿ Two-level or multilevel scales?◼Most use pass-fail or satisfactory-
unsatisfactory rating scales
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Common Errors With Rating Scales⦿ Leniency, severity, logical…errors⦿ Lack of interrater reliability◼ Do all evaluators agree on meaning of
competencies?• Conducts comprehensive assessment…
◼May be problem even when using descriptors with scale
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Common Errors With Rating Scales cont
⦿ Rater drift ◼ Definition or interpretation of
competencies to be assessed changes over time◼ Even if you prepare clinical teachers and
preceptors...drift over time
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Improving Use of Tool⦿ Prepare clinical teacher, preceptor,
others for using tool◼ Meaning of each competency◼ What would performance look like to
pass or fail, or at each rating level?◼ Norm: discuss competency and its
meaning + come to agreement among evaluators
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Improving Use of Tool cont
⦿ Have regular discussion of competencies to be rated
⦿ Annual evaluation of tool, process◼ What’s working? Not working?◼ Other data needed?◼ What methods would provide those
data?
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Rater Training⦿ Improve evaluator’s skill in
observing and rating performance⦿ Rater error training◼ Increase awareness of rater errors that
could occur and how to avoid them◼ Studies show if evaluators know
potential rating errors (eg, halo effect, leniency error), they are less likely to make them
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Rater Training cont⦿ Frame of reference training◼ Prepare evaluators to recognize standard
for rating performance• Reference point for evaluators to use
• Content oriented training
◼ Iterative process• Observe and rate performance, check
consistency in ratings, discuss discrepancies
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Use Multiple Evaluation Methods⦿ Observation ⦿ Assignments⦿ Papers (can be short)⦿ Concept maps⦿ Journals⦿ Short cases⦿ Post clinical conferences
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Use Multiple Evaluation Methods cont⦿ Simulations for summative
evaluation⦿ Standardized patients⦿ Objective Structured Clinical
Examination⦿ E-portfolios⦿ Others
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Clinical Evaluation Methods⦿ Method should provide data on
specific competency
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Incorporating Simulation into Evaluation Protocols⦿ Identify competencies to be assessed
with simulation⦿ Identify types of simulations needed
for those competencies⦿ Are simulations available or need to
be developed? ⦿ Formative or summative evaluation
or both?⦿ Train raters
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Standardized Patients⦿ Provides consistency in performance
evaluation◼ Recreate same patient condition and
clinical situation with each student
⦿ Provide written and oral feedback to students on their performance
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Objective Structured Clinical Examination (OSCE)⦿ Assess clinical competencies⦿ Students rotate through stations
where they perform assessments, clinical skills, procedures and are evaluated on them
⦿ Most use standardized patients⦿ Performance rated by multiple
examiners
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E-portfolios⦿ Documents in portfolio provide
evidence of meeting competencies◼ Requires reflection by student◼ Assessment: formative, summative or both
⦿ Systematic review◼ 69 studies (32 were nursing)
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Grading Clinical Practice⦿ Two criteria◼ Evaluation methods should reflect the
clinical competencies◼ Students must understand how their
clinical practice will be assessed and graded
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Grading Clinical Practice cont⦿ Decisions about assigning grades◼Which assessment methods for
summative evaluation and which for formative (feedback) only? ◼Will clinical grade be included in course
grade?
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Grading Clinical Practice cont⦿ Can be based on competencies met◼ Designate some as critical◼ 2 dimensional grading:
• Pass = all critical competencies met
• Fail = 1 or more critical competencies not met
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Grading Clinical Practice cont◼Multi-dimensional grading:
• A = all competencies met
• B = all critical competencies + half of others
• C = all critical competencies
• F = critical competencies not met
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Grading Clinical Practice cont⦿ Can be based on evaluation methods◼ Example 1:
Method % of GradeRating form (clinical evaluation tool)
50
Papers 20E-portfolio 30
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Grading Clinical Practice cont◼ Example 2:
Method % of GradeRating form (clinical evaluation tool)
Pass
Papers 40E-portfolio 40Presentation 20
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