Students' perspectives of same-day clinical assignments: a qualitative descriptive study.
The clinical experience is essential to the nursing education process, but the process by which students are assigned patients has remained unchanged for decades. The purpose of this qualitative descriptive study was to determine the acceptability of a same-day clinical assignment process from the perspective of pre-licensure nursing students. Students' (n = 104) perceptions of the same-day clinical assignment process were collected via focus groups. Two themes emerged that may assist educators in implementing new methods for clinical assignments.
KEYWORDS Pre-Licensure Nursing Education--Clinical Assignments--Qualitative Research Same-Day Clinical Assignment Process
The clinical learning experience is integral to nursing education. It is by this method that students learn, practice, and apply the skills needed to interact with and care for patients in the hospital environment.
It is essential that educators focus on teaching students how to use multiple resources and clinical reasoning in clinical settings (Benner, Sutphen, Leonard, & Day, 2010). The Institute of Medicine's (2011) Future of Nursing report calls for nurse educators to "think differently" about the educational/clinical experiences of students, suggesting that nontraditional ways of providing clinical education will enhance student learning and the ability to prioritize and apply situated knowledge.
In today's health care environment, the clinical assignment process can be challenging. Patients are admitted with complex medical diagnoses requiring highly skilled nursing care. In addition, hospital stays are short, with patients discharged to home within days of their admission (Tanner, 2006). Often instructors complete the student assignment process only to find that the assigned patients have been discharged home, leaving the instructor with the task of assigning a new patient(s) and the students with little time to study the diagnosis, review medications, and make other preparations.
Schools of nursing must find innovative solutions to the clinical assignment process. The purpose of this qualitative descriptive study was to explore pre-licensure students' perspectives of a same-day clinical assignment process that uses personal digital assistant (PDA) technology support.
Traditionally, clinical Instructors arrive on their assigned units a day In advance to review patient diagnoses and treatment plans. Student assignments are made based on Input from the unit's staff nurses, the students' learning needs, and course objectives. Some programs provide students with their patient assignment and clinical information in advance, while others post assignments at the clinical unit and students are expected to seek out their patients' medical information (Burke & Van Nostrand, 2008). This method of developing clinical assignments Is often costly due to expenses incurred by the school. There is also a loss of productivity by the hospital unit's staff and instructors during the visit to the hospital unit.
Some nursing education programs have forgone the hospital clinical assignment process entirely and assign students to patients the day of the clinical (Cannon-Diehl, 2009). However, under those circumstances, the care provided by nursing students to newly admitted patients may be of poor quality due to inadequate preparation. Students may require additional time, energy and oversight by the clinical instructor to ensure that the nursing care they provide is safe.
For the same-day clinical assignment (SDCA) process described in this article, students engaged in preparation for a period of four to five weeks. They were given lists of diagnoses, medications, and laboratory tests that were typical for patients admitted to their assigned unit and were required to research and study this information. The amount of Information provided decreased gradually, and at week 5, students began to receive same-day assignments.
The institutional review board of a large university in the Northeast approved this project. The sample consisted of 104 pre-licensure nursing students enrolled in the Adult Health I (n = 56) and Adult Health II (n = 48) clinical courses. All students enrolled In these courses were required to participate in this SDCA qualitative descriptive study.
THE SDCA PROCESS Instructors arrived on the unit early on the clinical day and chose appropriate patients. The SDCA process required students to arrive at their designated clinical unit, receive the nursing report, and use their PDA as a resource to develop a nursing plan of care. The entire process lasted 14 weeks, with 5 weeks of preparation and 9 weeks at the clinical site.
INTEGRATION OF PDA TECHNOLOGY Students enrolled in the Adult Health l/ll courses received a letter notifying them of the integration of PDA technology into their clinical courses. Students were required to purchase a PDA device compatible with Skyscape[R] software. This software was chosen because of its ease of use and the availability of textbooks that were already being used in the adult health courses. Instructors were assigned an iPod Touch with the same software installed; they received training on the device and software, along with policies and procedures for the project.
A HIPAA technology-use agreement was developed for students that detailed information about maintaining patient confidentiality and the proper conduct of behavior when using PDAs in the clinical setting. This agreement was reviewed and signed by students. At the beginning of each semester students and instructors received a refresher session on the use of the device and software and the project's policies and procedures.
A qualitative descriptive design, using a focus group method, was employed to elicit student feedback regarding their experience with the SDCA process. Focus group methodology is widely used in social science research to allow the researcher insight into a wide range of themes through group interactions (Redmond & Curtis, 2009).
Focus groups with four to six students per group, lasting 45 to 90 minutes, were conducted at the end of the semester. Adult Health I and II students were interviewed separately. The first author, who was not a member of the class instructor group, conducted the interviews. A semi-structured interview guide was utilized to guide the discussion and gather data. Written field notes were recorded and used in the analysis; all focus groups were audiotaped.
A HIPAA-trained transcriptionist transcribed the audiotapes verbatim. After being reviewed for accuracy, the transcripts were read numerous times by the researchers for data immersion. Content analysis, which included line-by-line coding, identified key phrases and led to the development of clusters that depicted participants' perceptions (Elo & Kyngas, 2008).
To increase rigor and validity, the results were discussed continuously and themes and subthemes were revised until agreement was achieved among the researchers. The final level of coding included the development of themes that were representative of the students' perceptions.
Two themes connected with the SDCA process emerged from the data. Themes connected with the PDA will be reported elsewhere.
Independence Like a Real Nurse
Students are often focused on learning about the patient's illness as well as on the tasks associated with caring for the patient. This theme speaks to the socialization of students into the nursing role. Students expressed that the SDCA process gave them independence and built their confidence in their ability to act like a "real nurse." One student stated, "I think it makes more sense. I like the fact that it [sameday assignments] caused you to think on your feet, which is more like what a real nurse does." Another student stated, "I like it [same-day assignments] because this is how it is going to be. Even when you receive assignments the night before it's not like you get all of the information ... getting assignments the same day you can ask questions or ... look things up on our Skyscape."
Students reported that the gradual decrease in patient information and requirement to learn common diagnoses and treatments was beneficial. This method help them learn: "Not knowing anything about the patient would have been a little daunting ... the gradual part of it is okay."
Viewing the Patient Instead of the Disease
Students told of having higher levels of anxiety and sleepless nights when they received their assignment the night before as with traditional clinicals. They spoke of finding a mismatch between the patients' medical appearance they worried about and their actual appearance. One student stated that she would "look up what a craniotomy is so you know what to expect" but too much information led her "in the wrong direction because you go there and see the patient and they're usually different from what you get."
Students reported less stress and anxiety with the SDCA process and found it beneficial and more efficient: "When I come in I can actually see what [the] patient has [patient diagnosis] and hear nursing rounds and then if there's something I'm unsure of I go and look it up." The SDCA process helped them view the patient as a person rather than as a disease.
Students in this project responded positively to the SDCA process. They also found the PDAs a useful adjunct for augmenting the care they provided to patients. Research has shown favorable student responses to PDAs in the clinical setting and in nursing education (George, Davidson, Serapiglia, Baria, & Thotakura, 2010).
The themes that emerged from the data highlight several interesting points. First, many students are fearful regarding the acuity of their assigned patients and often feel overwhelmed with learning the information necessary to provide safe nursing care. Students often reported that with the traditional clinical, they had limited time to learn patient information in advance due to conflicts with evening classes, receiving their assignments late, or their inability to prioritize the needed information. Many students reported that they often study late into the night (till about 2:00 am) to prepare for clinical.
Receiving common diagnoses, medications, and labs in advance provided the students with the opportunity for advanced learning and relieved the stress associated with clinical preparation. This advanced learning, as well as using the PDA with its associated references to supplement their clinical knowledge, appeared to increase the students' confidence in learning the nursing role.
The SDCA helped students view patients holistically. Students also stated that advance clinical preparation tended to skew their perceptions of the patient's condition and level of acuity, which added to their anxiety. Anxiety can decrease concentration and learning abilities. Instructors often spend large amounts of time working with students to decease their anxiety in the clinical setting.
This was a qualitative descriptive study within a school of nursing and not a controlled research project. In addition, data were not collected from faculty regarding their perceptions of the same-day assignment process. However, the positive qualitative perceptions of the students in our study support further investigation of this type of clinical learning process.
Schools of nursing are looking for innovative and cost-efficient ways to continue to provide clinical learning experiences to students. The SDCA process reported here provides an alternative to the routine clinical assignment process. Students viewed this process favorably.
Further exploration is needed regarding feasibility, usability, and cost-effectiveness.
The authors are faculty, Boston College William F. Connell School of Nursing, Chestnut Hill, Massachusetts. Allyssa L. Harris, PhD, RN, WHNP-BC, is an assistant professor. Kelly D. Stamp, PhD, APRN, ANP-C, is an associate professor. The authors would like to thank the following for their assistance and support in making this project possible: Jane Ashley, PhD, RN; Luanne Nugent DNP, MSN, RN, CNS; Stacey Hoffman Barone, PhD, RN, CNS; Doreen Behney Hurley, MSN, RN, CCRN; M. Colleen Simonelli, PhD, RNC; Heather Valient, MS, RN; Colleen Toronto, MS, RN; and Jeannie Foley. For more information, contact Dr. Harris at email@example.com.
Benner, P., Sutphen, M., Leonard, V" & Day, L. (2010). Educating nurses: A call faradical transformation. San Francisco, CA: Jossey-Bass.
Burke, B. K., & Van Nostrand, S. (2008). Managing logistics of clinical experiences. In B. K. Penn (Ed.), Mastering the teaching role: A guide for nurse educators (pp. 201 -208). Philadelphia, PA: F. A. Davis.
Cannon-Diehl, M. R. (2009). Simulation in healthcare and nursing. Critical Care Nursing Quarterly, 32, 128-136.
Elo, S., &Kyngas, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62,107-115.
George, L, Davidson, L, Serapiglia, C" Baria, S" &Thotakura, A. (2010). Technology in nursing education: A study of PDA use by students. Journal of Professional Nursing, 26,371-376. doi: 10.1016/i.profnurs,2010.08.001
Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.
Redmond, R., & Curtis, E. (2009). Focus groups: Principles and process. Nurse Researcher, 16, 57-69.
Tanner, C. (2006). The next transformation: Clinical education. Journal of Nursing Education, 45, 99-100.
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|Title Annotation:||Research Brief|
|Author:||Harris, Allyssa L.; Stamp, Kelly D.|
|Publication:||Nursing Education Perspectives|
|Date:||May 1, 2016|
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