In 2001, the Institute of Medicine (IOM) released Crossing the Quality Chasm: A New Health System for the 21st Century, which called for radical changes to the U.S. health care delivery system and the education of providers. The IOM called for clinical education to focus on evidence-based practice and the use of decision-support technology to improve clinical decision making. Specific skills suggested for providers in the IOM report included working in teams and improving communication with patients. Educational programs are instrumental in modeling a change from individual and memory-based care to a collaborative model that relies on high-quality references.
The need for primary care providers continues to rise, especially in underserved areas where the population has more chronic health conditions (Dower & O’Neil, 2011). Several advanced practice nursing specialties are now including primary care competencies to meet this demand and to provide clinicians with valuable skills (American College of Nurse-Midwives, 2012; National CNS Competency Task Force, 2010). However, as more educational programs include these competencies, existing specialty faculty may not be qualified to teach the new content, and due to the shortage of qualified faculty, recruitment of qualified instructors is difficult (Fang & Li, 2011).
The course we sought to revise was a primary care practicum and included 126 hours in a variety of clinical sites and weekly clinical conferences at the school of nursing. The course lasted for 6 weeks and was offered twice in one semester. The goal of the course was to improve student clinical reasoning and performance in the clinical setting. The revision focused on the clinical conference, which met for one orientation and six 2-hour sessions, and focused on modeling clinical reasoning and charting.
All students within the course were RNs earning a Master of Science in Nursing. Advanced physical assessment was a prerequisite to the course. Corequisites included the didactic courses Primary Care of the Adult and Advanced Pharmacotherapeutics. The course involved a total of 30 students and three faculty during the semester, with 15 students in the primary care setting at one time. Although this course revision was performed to enhance student learning, institutional review board approval was obtained to allow dissemination of results.
The guiding theoretical framework for the course was constructivism, which values the learning process more than the learning product (Merriam, Cafferella, & Baumgartner, 2007). Class time was spent providing the students with a well-structured opportunity to learn and practice clinical reasoning and assessment, giving them the opportunity to learn and improve prior to grading. Mezirow’s (1997) theory of transformative learning was another influence in revising the course, as students were provided with a disorienting dilemma to spur their learning and encourage transition from nurse to nurse practitioner.
The overarching goal of the course was to model the clinical reasoning skills essential to the care of patients in ambulatory settings. The faculty wanted the students to be able to sift through didactic knowledge and assessment skills to perform targeted histories and physical assessments in response to patients’ presenting problem(s). By the end of each conference session, students were expected to develop an evidence-based plan of care for the patient and to produce a clear, concise, and complete chart note. Students also noted the criteria to evaluate the effectiveness of their plan of care and identified the next step if their initial treatment was ineffective.
Faculty reinforced the fact that evidence is constantly changing, and they encouraged students to use high-quality references when they needed information. Congruent with evidence that peer-to-peer learning and teaching is effective in knowledge transmission and in increasing the ability to work in professional teams (White, Rowland, & Pesis-Katz, 2012), opportunities were provided for peer-to-peer learning, while maintaining individual grades. Grades reflected learning, effort, and process, rather than initial knowledge or first effort.
Course faculty generated a list of common primary care chief complaints (e.g., abdominal pain, chest pain, and headache) that required clinical reasoning and current knowledge. Three unique cases were generated for each of the six class sessions. Complete case files were made available for faculty use, which included a patient picture, demographic characteristics, presenting signs and symptoms, physical assessment findings, and pertinent laboratory results. Stern’s, Cifu’s, and Altkorn’s (2010) Symptom to Diagnosis: An Evidence-Based Guide was the primary source used in case development. Cases were altered to fit course objectives and learning levels and were designed to be challenging but manageable within approximately 1 hour. A patient chart was created for the students, which included information typically provided in a patient chart prior to his or her clinic visit: basic demographic information, pertinent history, chief concern, and vital signs.
Simulation allows students to learn new behaviors, skills, and knowledge in a safe environment (Rutherford-Hemming, 2012). Because students had successfully completed advanced physical assessment, this course focused on clinical reasoning, patient interaction, assessment, and planning. We chose lowfidelity simulation as our in-class teaching method because we wanted students to be methodical and focus on the clinical reasoning process, rather than the physical assessment of a lifelike manikin. A high-fidelity simulation could have been used to enhance the students’ physical assessment skills or encourage situational awareness in complex environments. However, low-fidelity simulation also allowed us to use faculty as simulated patients and permitted three cases to be run simultaneously without any equipment. Because simulation requires a certain amount of suspension of disbelief, students were asked to pretend that the regular classroom was a clinic and that the faculty members were simulated patients (Schiavenato, 2009).
Each simulation session was structured around the SOAP (subjective, objective, assessment, and plan) note format, which is similarly used in regular clinic visits. Although the students would talk with only one simulated patient, they were asked to come to conference prepared to assess the chief concerns of three different patients. Groups of three to six students were given the simulated charts and were asked to generate a list of differential diagnoses for the patient’s concern and determine what subjective and objective information needed to be obtained to rule in or out all diagnoses. The students were allowed to consult resources at this point, but their preparation for class allowed them to move quickly through this collaborative work. The students in each group then divided the tasks for the session, with one to two students assigned to each task. One task involved using texts, handbooks, and Internet-based resources to guide the questioning, physical examination, and laboratory results. Simultaneously, other students either talked with the patient or developed the SOAP note using Google™ Docs.
Once students had planned for the “patient visit,” the faculty clipped the patient’s picture to their ID tags and assumed the role of that patient. Students were encouraged to conduct a routine patient visit, beginning with introductions and then allowing the patient to state the problem in his or her own words. Students often struggled with taking an organized and comprehensive history, even in a group. The simulated patient provided no guidance but did point out in patient-appropriate language if the questions seemed strange or disorganized.
Following a detailed history, the students could ask the simulated patient about specific physical examination findings and receive a report of the results. For instance, the students would state “I would listen to his lungs in all lobes bilaterally,” and the faculty would answer, “My lungs are clear to auscultation bilaterally and in all lobes.” To increase student familiarity with charting of normal and abnormal findings, faculty encouraged students to ask questions using anatomical terms for which the faculty answered with the correct terminology. Students could “order” laboratory tests and were given results immediately to streamline the clinical decision-making process.
Following the history and physical examination, students pretended to step out of the room and then worked together to review the assessment and develop a comprehensive plan of care for that patient. If medications were needed, the students had to write a complete prescription using a simulated prescription pad and include all information in the SOAP note. Following planning, the students were encouraged to return to the simulated patient’s room and discuss with the patient the options for care and perform any necessary teaching.
Students were required to add an evaluation (E) section to their SOAP note, which addressed the criteria to determine effectiveness of treatment. For instance, “When should the cough or fever resolve?” “How long will it take for the antihypertensive prescription to work?” “What is the ideal range for the patient’s blood pressure?”
The formation of the SOAP+E note generally took 1.25 hours, then the groups came back together, and a family nurse practitioner (FNP) faculty member was brought into the classroom to provide external feedback. The FNP faculty was aware of the entire patient case and therefore could easily identify student errors. The groups took turns presenting, while displaying their SOAP+E notes on the screen in front of the class, and the FNP expert provided advice similar to grading but with greater commentary. Because the FNP expert was not part of the initial role-playing, he or she had a fresh perspective on the case and was able to point out items left out of the documentation. The students were allowed to correct their SOAP+E note in response to feedback prior to submission for grading. If students had omitted sections of the history or physical, they had to note this in italics to show it was not done within the visit. The students were required to submit their individual notes to the online class platform within 6 hours after class. This allowed students time to make individual changes, while encouraging timely charting. The grading burden of the individual SOAP+E notes was minimal, as the notes had already received critique and feedback from the FNP experts during class.
Although primary care has been a core competency for nurse-midwifery since 1997 (Avery, 2005), few qualified nurse-midwifery faculty provide a substantial amount of primary care in practice (Hastings-Tolsma, Emeis, McFarlin, & Schmiege, 2012). FNPs were included in the course as experts, but this required minimal time commitment. Once per week, one FNP faculty member spent 45 minutes providing feedback on three SOAP+E notes.
Student evaluations of the course were uniformly positive. Students commented favorably on the format of the clinical conference, as indicated by one student:
The way case studies were presented and you worked with other classmates to “assess the patient” and form diagnoses and treatment plan, as well as tailor SOAP notes, was [a] great experience. I feel we all learned so much from this format. I do like being able to go back that evening and redo the SOAP if I feel something was left out or should be worded differently. It helped me learn what terminology to use and to make sure I covered all the bases—that way I will remember when I have that type of patient—what all is needed to be assessed and documented and taught and screened for. Excellent way to put into practice what we are learning and cement the patient interview, assessment, and SOAP note.
Preceptors commented on this group’s ability to integrate skills and knowledge:
I was impressed with (student [name])’s knowledge base and skill set as a student NP. She was able to see the bigger picture with patients and put together all of the patient information both past and present with ease. She demonstrated excellent interview skills, and was able to pick out abnormalities on assessment. She was also able to develop appropriate differential diagnoses. In addition to this, she made patients and family members feel at ease.
Although it is difficult to compare a nonrandomized, educational intervention, faculty from later courses commented on this group’s ability to format comprehensive and concise SOAP notes, compared with students from other specialties who did not have this type of clinical simulation. As a result of the increased competence of these students, the FNP program plans to implement a modified version of this course within its curriculum.
The willingness of the FNP faculty to assist in a nurse-midwifery course made this course format possible. Although the faculty’s time demand was minimal, it still represented additional effort. FNP faculty were recruited with the whimsical offer of a gourmet cupcake, and they were given thank-you letters for their promotion files. An unintended positive side effect of the course format was collaboration between the FNP and nurse-midwifery faculty. After spending time with midwifery faculty and recognizing their eagerness for collaboration, FNP faculty invited nurse-midwifery faculty to guest lecture in their classes as well. Schools of nursing could benefit from greater collaboration between nurse specialties to model cooperation among practitioners, consistent with IOM goals.
In previous years, clinical conference time had focused on students’ case presentations. Although student-led, this approach was problematic in several ways. First, the students tended to choose complex cases because they were exciting, but their presentations did not reflect a depth of knowledge or the clinical reasoning process. Student-initiated cases also tended to reflect unusual diagnoses that were uncommon to primary care. Due to patient complexity, students were often reporting preceptor-collected information, and they did not incorporate newer evidence-based interventions such as those taught in class. In addition, the nurse-midwifery faculty were unable to clearly evaluate the assessment and planning of complex cases beyond their usual scope of practice.
Low-fidelity simulation provided greater control of clinical conference time and kept the students focused on the most frequent differential diagnoses seen in primary care. In addition, the course modeled clinical reasoning skills, evidence-based care, and concise and thorough charting. Although this course format did represent an increase in faculty responsibility for student learning, its positive benefits for the introductory student outweighed any additional preparatory time.
Many nursing programs include online components to their curricula. Because lectures are easy to package into an online environment, faculty are considering how to make the most of on-site time with students. This clinical conference format uses simulation to guide students through clinical reasoning and gives faculty the opportunity to observe patient communication, charting, and formulation of an evidence-based plan of care in a safe environment.
In 2010, after reviewing quality of care studies provided by advanced practice nurses, the IOM recommended that nurses be prepared to practice full-scope, primary care to meet the health care needs in the United States (The Patient Protection and Affordable Care Act, 2010). The collaborative teaching example provided demonstrates cost-effective, efficient use of faculty time to teach principles of primary care management in a safe, low-stress environment.
- American College of Nurse-Midwives. (2012). Core competencies for basic midwifery practice. Retrieved from http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000050/Core%20Comptencies%20Dec%202012.pdf
- Avery, M.D. (2005). The history and evolution of the core competencies for basic midwifery practice. Journal of Midwifery & Women’s Health, 50, 102–107 doi:10.1016/j.jmwh.2004.12.006 [CrossRef] .
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- Fang, D. & Li, Y. (2011). Special survey on vacant faculty positions for the academic year 2011–2012. Washington, DC: American Association of Colleges of Nursing. Retrieved from http://www.aacn.nche.edu/leading-initiatives/research-data/vacancy11.pdf
- Hastings-Tolsma, M., Emeis, C., McFarlin, B. & Schmiege, S. (2012). 2012 task analysis: A report of midwifery practice. Linthicum, MD: American Midwifery Certification Board. Retrieved from http://www.amcbmidwife.org/assets/documents/TA%20for%20Website.pdf
- Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
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- The Patient Protection and Affordable Care Act of 2010, Pub. L. 111–148, § 18001, 124 Stat. 119 (2010).
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- Stern, S.D.C., Cifu, A. & Altkorn, D. (2010). Symptom to diagnosis: An evidence-based guide (2nd ed.). New York, NY: McGraw-Hill/Lange Medical Books.
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