Journal of Nursing Education

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Guest Editorial 

From Random Access Opportunity to a Clinical Education Curriculum

Nurse educators have been initiating multiple strategies in response to the current and projected nursing shortage. Increasing the enrollment of nursing students is one such immediate strategy to address the complexity of this problem. However, this strategy alone is simply not sustainable unless substantial changes are made in how nursing schools integrate clinical learning to prepare students. The traditional clinical education model is taxing faculty, facilities, students, and staff, and increasingly relies on the availability of clinical placements. This makes it difficult to ensure that students get a planned experience with a variety of patients. Students need experience with patients across the lifespan, and ample learning experience with patients with prevalent illness and disease should be included (Tanner, 2006). Students also need to understand the trajectory of chronic illness and management of end-of-life care. But the current model of clinical education is increasingly driven by availability of clinical placements, not by experience that correlates with course outcomes or competency development. The traditional model of clinical education has been referred to as “education by random opportunity” (LeFlore, Anderson, Michael, Engle, & Anderson, 2007, p. 170).

The Oregon Consortium for Nursing Education (OCNE) is developing new clinical education practices to complement a shared competency based curriculum that is being delivered throughout Oregon. A group of educators and practice partners associated with OCNE schools was formed with the charge to study current clinical education practices and develop a comprehensive clinical education model that spans the OCNE curriculum.

Clinical Education Curriculum

Curriculum connotes the planned staging of learning activities to accomplish course outcomes. In the case of clinical education, the desired outcome is the students’ ability to apply course competencies in the practice arena and in so doing, to take on the practice of nursing. The term learning model signifies that each model is an integrated set of activities. There are five learning models in the proposed OCNE clinical education curriculum. Learning models build on one another, adding complexity appropriate to the level of the student. The five models are described below.

Learning Models

Focused Direct Client Care Experience

Focused direct client care experience enables the student to gain progressive experience in the delivery of client care, where the client may be an individual or family in the acute care, long term care, or community care arena. A focused direct client care experience is differentiated from the total patient care experience by carefully identifying the nursing activity or practice to be studied during the clinical time.

Concept-Based Experience

Concept-based experience is focused on the outcome of learning, which is associated with an identified concept. In this model, the student is studying the patient regarding the concept to be learned and is not responsible for care outcomes. Students are accountable for all aspects of care provided as a consequence of studying the patient and for patient safety, as well as communication of changes in client condition to the client’s care provider.

Case-Based Experience

Case-based experience provides for practice of clinical judgment and nursing performance through client care exemplars. It encompasses seminar discussion of cases, as well as a variety of simulations, including use of high and low technology manikins, standardized patients, and role-playing. The OCNE curriculum includes a number of “mega-cases” that are designed as exemplars of highly prevalent health care situations.

Intervention Skill-Based Experience

Intervention skill-based experience has the primary purpose of building proficiency in the “know-how” and “know-why” of nursing practice for those skills best learned through repetition. Common intervention skill-based experiences focus on psychomotor, communication, teaching, and advocacy skills, among others. As the student’s skill level increases, complexity can be added through the integration of the skills into case-based experiences so the student has the opportunity to practice the clinical judgments associated with the skills being studied.

Integrative Experience

Integrative experience provides the opportunity for the student to pull all prior learning into a real clinical practice situation. All competencies would be in play, with the focus on integration and refinement in a real setting. This is also an opportunity for the student to be integrated into the practice community and begin the transition from the student role to the professional nurse role. It is the primary kind of learning activity in the final clinical experience of the program. Shorter experiences will occur periodically throughout the curriculum to provide opportunity for integration of learning related to a particular population.

Summary

The purpose of the clinical education curriculum is to improve student achievement of course competencies through the creation of structured learning experiences that are scaffolded to the curriculum and the level of the student; to ease the strain of clinical education on the clinical agencies; and to ease the transition of the student role to that of the professional nurse. As educators, we realize that we can no longer rely on random access opportunity for the development of practice skills. We must structure our clinical education, like we structure our course content, to be appropriate to the learning outcomes and the developmental level of the student. Several of the OCNE learning models are currently being developed and evaluated as OCNE pilot projects. As the curriculum is implemented, OCNE will continue to evaluate the effectiveness of the learning models and the combined effect of the integrated curriculum of achievement of the goals of the program.

Paula Gubrud-Howe, MS, RN
Oregon Consortium for Nursing Education Project Staff

and

Mary Schoessler, EdD, RN
Oregon Consortium for Nursing Education Project Staff Portland, Oregon

References

  • LeFlore, JL, Anderson, M, Michael, JL, Engle, WD & Anderson, J2007. Comparison of self-directed learning versus instructor-modeled learning during a simulated clinical experience. Simulation in Healthcare, 2, 170–177.
  • Tanner, CA2006. The next transformation: Clinical education. Journal of Nursing Education, 45, 99–100.

Editor’s Note:This issue of the Journal of Nursing Education presents clinical education from a variety of perspectives. Two major themes run through the articles in this issue. The first is the need for capacity building in prelicensure programs (see the article by Hofler) and the need for collaboration to achieve it. The second, less apparent theme (except by its absence) is the dearth of research on learning outcomes achieved through clinical education. The review by Udlis about research on preceptorships underscores the critical need for more research on our approaches to clinical education. Her work documents that this widely used approach to clinical education has not been consistently supported by studies examining its effectiveness.

Faculty and their partners, through the Oregon Consortium for Nursing Education, are attempting to both build capacity through their collaborative endeavors and address this significant gap in research. They are doing so first by developing a strong conceptualization of how clinical education could proceed, then by testing its effectiveness. Our guest editors for this issue, Mary Schoessler and Paula Gubrud-Howe, provided a preview of this important work and a framework that may begin to guide other research on clinical education.

~ Christine A. Tanner, PhD, RN

10.3928/01484834-20080101-02

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