The gap between theory and practice for nursing graduates has been widely documented in the literature (Benner, Sutphen, Leonard, & Day, 2010; Berkow, Virkstis, Stewart, Aronson, & Donohue, 2011; Hatlevik, 2011; Tanner 2010). Strategies and structures that better integrate students into the clinical practice setting are needed to integrate didactic and clinical curriculum components and improve clinical nursing education (Benner et al., 2010; Jacobson & Grindel, 2006; Svejda, Goldberg, Belden, Potempa, & Calarco, 2012; Tanner, 2010). The purpose of this project was to identify a mechanism that would promote integrative learning between classroom theory and clinical practice, increase student accountability for learning, and facilitate communication of the student’s specific learning needs with nurse mentors and faculty.
Background and Nursing Significance
Benner et al. (2010) identified three areas of experiential and integrative learning that require interaction with a community of practice, situational coaching by teachers, and demonstration of aspects of a complex practice that are not easily translated. Specifically, three broad and inclusive areas were identified as encompassing the domain of professional knowledge and nursing practice: (a) cognitive knowledge and science, (b) clinical reasoning and practical skilled know-how, and (c) ethical comportment and relational formation (Benner et al., 2010).
The realm of acquired cognitive knowledge and science includes the sophisticated understanding of chemistry, physiology, pathophysiology, microbiology, physics, genetics, pharmacology, genomics, and more (Benner et al., 2010). In addition, Benner et al. (2010) emphasized that nurses must keep pace with care implications of research. An example of student learning pertaining to cognitive knowledge acquisition could be an in-depth understanding of the client’s pathophysiology and relationship to the clinical picture.
Clinical reasoning and practical skilled know-how is composed of the use of knowledge from many fields to grasp the nursing implications of a clinical situation, master complex technical skills, develop astute clinical judgment to interpret situations, and communicate with the health care team, patients, and families (Benner et al., 2010). Examples of clinical reasoning skill development include competency in intravenous heparin administration or understanding the assessment and monitoring of a patient after an angiogram has been performed.
Finally, it is necessary that nurses grasp ethical comportment and relational skills, demonstrating the appropriate use of knowledge, skills of care, development of therapeutic patient and family relationships, and communication with patients, families, and the health care team (Benner et al., 2010). Clinical examples include identification of the socioeconomic characteristics of the patient, including the potential implications of this on the patient’s illness trajectory, or discussion with patient family members about the initiation of palliative care.
The University of Michigan School of Nursing and the University of Michigan Health System implemented the final phase of a partnership model for clinical education, known as the Clinical Excellence Initiative in fall 2011 (Svejda et al., 2012). Within this model, the nurse mentor (e.g., staff nurse), student, and faculty member become a triad to educate the student as a clinical team. The nurse mentor assumes a direct role in student education and uses clinical faculty for guidance in conducting the student’s experience.
Student communication with nurse mentors and faculty regarding the student’s learning needs is critical in the partnership model. For this reason, the Clinical Goals Initiative was developed and implemented. This initiative was grounded within the areas of necessary experiential and integrative learning identified by Benner et al. (2010). The focus was to encourage empowerment of students in directing their own learning, promotion of autonomy, and enhancement of professionalism (Espeland & Shanta, 2001). Prior to the Clinical Goals Initiative, students had been asked to develop one clinical goal each week. Examples of student developed goals include, “I will complete a full assessment on my patient,” “I will pass [medications] on my patient,” and “I will insert a urinary catheter.” Faculty noted that the goals developed by the students primarily focused on skill development, rather than on knowledge and ethical aspects of care that are required for effective nursing practice. The faculty believed that by empowering students to develop comprehensive goals to direct their learning in the clinical setting, improved communication and accountability would ensue.
The Clinical Goals Initiative consisted of student-directed learning, whereby the student identified three types of goals for the weekly clinical experience. In an effort to broaden students’ clinical focus, the Clinical Goals Initiative required students to come to each clinical experience with three goals, including a cognitive knowledge and science goal, a clinical reasoning or practical skilled know-how goal, and an ethical comportment or relational formation goal. It was believed that these goals would comprehensively direct the learning needs of the student in the key areas Benner et al. (2010) identified as essential for integrative learning and translation of knowledge to practice. The Clinical Goals Initiative was implemented throughout all student levels (e.g., sophomore, junior, and senior) in all clinical areas, including obstetrics, pediatrics, psychology, and medical–surgical units. Faculty explained guidelines for goals development and gave examples for the three types of goals to students and nurse mentors. Students were encouraged to share their goals daily with their nurse mentor and faculty to guide their clinical experiences. Reflection was encouraged afterward to identify whether the goals were met. This Clinical Goals Initiative project was approved by the institutional review board.
The Clinical Goals Initiative was evaluated at the end of the semester, approximately 6 weeks after implementation. Two surveys were developed by the investigators to evaluate the perceptions of students and faculty regarding the success of the goals initiative. The student survey included 11 questions, eight of which required a yes or no response and three that required an open-ended response. The specific survey questions were:
Did you share clinical goals each clinical day?
If yes, did you develop cognitive knowledge goals?
If yes, did you develop skills/clinical reasoning goals?
If yes, did you develop ethical/relational goals?
Did you share your goals with your RN each clinical day?
If no, what kept you from sharing your goals?
Did your goals facilitate your clinical learning?
Did you use feedback from the faculty to guide development of your next week’s daily goals?
Did you use feedback from the nurse mentor to guide the development of your next week’s daily goals?
What was the most beneficial aspect of setting daily goals?
What was the least beneficial aspect of setting daily goals?
Faculty were asked to complete a seven-item survey to determine their perceptions of the goals initiative. The survey included yes-or-no (n = 4) and open-ended (n = 3) questions asking for faculty’s report on the consistency of students sharing their goals (and types of goals) with the faculty and nurse mentors, their perception of the impact on student learning, and the most and least beneficial aspects of the goals initiative. Specifically, questions included:
Did the students share goals each clinical day with you?
If yes, were there cognitive knowledge goals?
If yes, were there skills/clinical reasoning goals?
If yes, were there ethical/relational goals?
Did the goals facilitate the student’s clinical learning (how/how not)?
What was the most beneficial aspect of having the students set daily goals?
What was the least beneficial aspect of having the students set daily goals?
Both the student and faculty surveys were administered electronically using Qualtrics® survey software. An e-mail, with a link to the survey, was sent to students and faculty to request anonymous feedback on the goals initiative. A reminder to faculty and students was sent 2 weeks after the initial request. Responses from the surveys were analyzed via frequencies for yes-or-no questions. Content analysis was conducted on the open-ended questions. The thematic content analysis approach, adapted from Glaser’s and Strauss’s grounded theory methodology (Burnard, 1991), included individual review and identification of themes within the responses. The investigators then met and reviewed the themes identified. Any discrepancies were discussed until consensus was achieved.
Student-developed goals postinitiative were more specific and inclusive of the three broad areas. Goals varied in complexity according to the level of the students. Examples of goals developed by students included:
- Knowledge: “I will understand the pathophysiology of cystic fibrosis and impact on oxygenation of my patient” (sophomore level). “I will understand the pathophysiology, clinical symptoms, laboratory indicators, and treatment options of a patient experiencing acute kidney injury” (junior level). “I will understand the effects of sleep deprivation in the intensive care unit and implement best practice nursing interventions to facilitate patient sleep and prevent delirium” (senior level).
- Clinical judgment: “I will demonstrate the ability and judgment required to insert and monitor a patient with an indwelling urinary catheter” (sophomore level). “I will demonstrate the ability to interpret sinus rhythm [electrocardiogram] telemetry strips” (junior level). “I will demonstrate a complete and accurate delirium assessment of the patient in the intensive care unit and implement appropriate nursing interventions to effectively manage it” (senior level).
- Ethical: “I will discuss noncompliance with adherence to [warfarin sodium] therapy” (sophomore level). “I will discuss quality of life issues with the patient who has chronic back pain” (junior level). “I will discuss with my nurse mentor how palliative care discussions are introduced to a patient and their family, and identify specify nursing interventions to assist with grief management” (senior level).
Faculty (N = 14) responded to the survey and reported that 85.7% of students shared their goals with them during the clinical day. Goals shared with the clinical faculty included cognitive (71.4%), skill (85.7%), and ethical (64.3%) types of goals. Faculty found that busy, intense clinical environments may have prevented the remaining students from sharing their goals with faculty. In addition, if faculty did not explicitly ask the students what their goals were, then they were often not shared. Faculty perceived that the goals initiative facilitated the students’ clinical learning when developed and shared appropriately. Student goals prior to the initiative lacked direction, depth, or specificity for learning. Following the initiative, student goals became more learning focused and inclusive of the three broad areas of knowledge, clinical judgment, and ethics. Additional comments from faculty included that the goals provided structure, guidance, and focus to the clinical experience; increased student ownership and responsibility; provided a more holistic approach to patient care; increased their understanding of different facets of learning; and increased organization and engagement by the students. The Clinical Goals Initiative also directed student faculty interactions. For example, faculty reviewed the students’ goals from the week before and asked questions related to attainment of these goals (e.g., “I see that your goal from last week was to understand the process of organ procurement. What did you find out?”). When asked the least beneficial aspect of the goals initiative, faculty noted the short time frame of the initiative and its introduction midway through the semester, as well as the time required to review and discuss the goals. Faculty expressed concern that some student goals were vague or simple. Students lacked the ability to develop appropriate goals in each of the three areas (e.g., the ethical goals) and, at times, lacked engagement in the process of goal development.
Students (N = 73) responding to the survey reported consistent development of the cognitive (81.9%) and reasoning or skill (86.4%) types of goals, with fewer students reporting consistent development of ethical or relational types of goals (63.6%). Students identified sharing their weekly goals with their faculty 74% of the time. In contrast, students reported sharing their goals with their nurse mentor only 40.8% of the time, stating that barriers to sharing the goals included time constraints, perceived lack of interest from mentors, lack of relevance to the patient assignment, and perception of the personal nature of the goals (e.g., “I developed them for me”). Students reported using the previous mentor (49.3%) and faculty feedback (59.7%) to develop subsequent goals.
Approximately 52% of students believed the Clinical Goals Initiative facilitated learning in the clinical environment. The students responded that they perceived the goals were beneficial in providing a focus and guidance in planning their clinical experience, facilitated articulation of areas needing improvement, optimized learning opportunities and experiences, and supported greater student engagement. When asked what was least beneficial about the initiative, students indicated that the three goals were tedious, unrealistic, and time consuming. Students were concerned about completing the goals prior to the clinical experience, as their subsequent patient assignment at their next clinical experience did not always allow attainment of the goals developed (e.g., a goal to identify the pathophysiology related to cardiomyopathy required a patient with that particular diagnosis).
The University of Michigan School of Nursing Clinical Goals Initiative was implemented in an attempt to improve the structure of student clinical experiences, facilitate communication with nurse mentors, and empower students for self-direction in clinical learning. This initiative broadened the scope of student-developed goals from a superficial, undirected, or skills-only focus into more holistic goals related to their knowledge, clinical judgment, ethical issues, and relationship formation. Faculty overwhelmingly supported the Clinical Goals Initiative, citing many benefits for student learning and enhancement of accountability. Students were generally positive about the application of the three types of goals when they fully understood their use through guidance by faculty.
To promote successful implementation in future semesters, modifications of the Clinical Goals Initiative will include a clearer and more consistent explanation of the three types of goals to faculty, students, and nurse mentors. In particular, students had difficulty formulating ethical comportment and relational types of goals and will need further explanation and examples of this goal type. Didactic course content should correlate with ethical content relevant to clinical practice so that students can obtain a deeper knowledge of ethical comportment. Nurse mentors will also be given additional support to help them to understand the use and purpose of the goals in shaping the students’ clinical learning experiences; this support will involve explicit video examples of student–nurse interactions with goal identification, clear examples of the three types of goals appropriately leveled for the type of student with whom they are working, and clear identification of student responsibilities in sharing their goals with the nurse. Finally, students should be held accountable for weekly goal development by reviewing goals with their instructor prior to the beginning of their shift, as well as submitting reflections of their goals by the end of their clinical week.
Further evaluation of the Clinical Goals Initiative will include the perceptions of nurse mentors in terms of benefits and drawbacks to using the student-directed goals in guiding the students’ clinical experiences, as well as additional faculty and student feedback.
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