Facilitating effective clinical learning for pediatric nursing students is an ever-evolving challenge. Traditional hospital settings are oversaturated for student clinical learning experiences and thus are increasingly more restrictive on student activities and limited in opportunities to experience global growth and development concepts. The majority of injured or ill children are not hospitalized; therefore, opportunities to interact and communicate with children and their families are more prevalent in alternate settings (Agency for Healthcare Research and Quality, 2008). Professional nursing organizations encourage nurse educators to be creative in finding alternative clinical experiences that support classroom knowledge. Yet, hospital leaders are concerned about the clinical judgment and prioritization skills of new graduates and many believe that inpatient clinical experiences are the only way to develop these skills (Berkow, Virkstis, Stewart, & Conway, 2009; Del Bueno, 2005; Tanner, 2010). Unfortunately, there is limited research to support or negate these assumptions. Gubrud-Howe and Schoessler (2008) stated that the traditional clinical model of nursing education is “taxing faculty, facilities, students, staff, and increasingly relies on the availability of clinical placements” (p. 3). Referring to this type of model as “education by random opportunity,” Gubrud-Howe and Schoessler noted that students do not gain adequate learning opportunities through this method. They further state that educators “must structure our clinical education, like we structure our course content, to be appropriate to the learning outcomes” (p. 4).
The purpose of our study was to compare the effectiveness of three different clinical teaching schedules in preparing nursing students to care for children and their families in the pediatric setting. The researchers sought to answer two questions:
- Can clinical reasoning and judgment be cultivated in settings other than hospitals?
- Is there a minimum amount of time that students must spend in inpatient settings?
The rapidly changing health care environment has posed many challenges for nursing education, particularly in the clinical arena. Augspurger and Rieg (1994) and Tanner (2010) described traditional clinical experiences as being centered in the acute care in-hospital settings, which do not meet the expanding and active roles of today’s nurse. Del Bueno (2005) reported that 35% of new graduate staff do not meet industry entry-level clinical judgment expectations.
Evidence is abundant that an evolution in nursing education is imminent and necessary. At the beginning of the 21st century, the American Association of Colleges of Nursing (1999) identified that this evolution would require a greater relationship among the teaching, community service, practice, research, and external environments. Grealish and Kaye (2004) and Gillespie and McLaren (2010) proposed contemporary clinical education and suggested the need for nursing education to shift the focus away from the traditional medical model toward care that entails a more holistic understanding. Gillespie and McLaren noted that clinical placements in nontraditional settings were found to have a positive impact on students’ development of clinical skills, career choices, and attitudes toward clients.
In more recent studies, the primary barrier to clinical nursing education has been identified as a lack of quality clinical sites (MacIntyre, Murray, Teel, & Karshmer, 2009; McNelis, Fonacier, McDonald, & Ironside, 2011). In addition, MacIntyre et al. (2009) proposed implementation of innovative partnerships between academia and clinical practice. Oermann and Heinrich (2006) stated that “we need to look to the community to assist in meeting learning needs of students” (p. 56) and to use service learning to accommodate more students than can be accommodated in hospital placements. Besides the decreases in clinical site availability, the health care environment is changing. The Institute of Medicine identified that “less than 20% of nursing practice time was devoted specifically to patient care activities” (McNelis et al., 2011, p. 65). The focus of pediatric nursing has changed from task-oriented care to coaching, coordinating, and teaching (McNelis et al., 2011). In the pediatric realm, most sick or injured children are not hospitalized, and the Agency for Healthcare Research and Quality (2008) indicates that only 18% of hospital stays in the United States are for children. According to the U.S. Department of Health and Human Services (Bloom, Cohen, & Freeman, 2012), most children have a usual primary care provider outside of the hospital setting. Most children (74%) use a doctor’s office as the usual place of health care, and 24% of children are seen in community clinics. The remainder are seen in hospital outpatient clinics, and only 1% are seen in the emergency department as the usual place of health care (Bloom et al., 2012).
According to Hitt and Overbay (1997), pediatric nursing more often occurs outside of the hospital setting and pediatric nursing education and “can be found in unexpected places” (p. 340). From a child health perspective, community-based and out-of-hospital experiences have been promoted and used by many educators (Augspurger & Rieg, 1994; Gance-Cleveland & Gilbert, 2001; Goetz & Nissen, 2005; Hitt & Overbay, 1997; O’Keefe & White, 2006). Benefits of community-based clinical experiences include increased learning opportunities, observation of the influence of social and environmental factors on children, and naturalistic and more realistic observation of growth and development (Goetz & Nissen, 2005; O’Keefe & White, 2006). In fact, Haussler and Cherry (1993) discussed a shift to the use of community settings as a primary child health clinical site.
Unfortunately, despite the calls for change and the anecdotal reporting of limited experiences, the related literature and research is lacking. According to McNelis et al. (2011), there is a “lack of evidence supporting student learning” (p. 65) in clinical settings. MacIntyre et al. (2009) also described a lack of published evidence establishing the amount of clinical time needed to produce learning outcomes in the clinical setting. The need for more research on clinical teaching effectiveness is encouraged in the literature (Gance-Cleveland & Gilbert, 2001; Grealish & Kaye, 2004; MacIntyre et al., 2009; McNelis et al., 2011; Tanner, 2010). In 2008, Oermann found “little direction in the current literature. A literature search for information related to the problem of clinical education capacity yielded only a few articles with suggestions for solving this dilemma” (p. 105).
Program and Course Background
Data were collected during a pediatric nursing course in an undergraduate baccalaureate nursing program. The course is taken during the third semester (Senior I), during which students are also enrolled in two other clinical courses—Adult Health II/Critical Care and Mental Health. Previous prerequisite clinical courses include Women’s Health/OB, Concepts/Fundamentals, and Adult Health I/Medical–Surgical. The clinical courses in this curriculum occur simultaneously across 16 weeks with classroom teaching, which is mostly content focused. Classroom teaching in the pediatric course incorporates a variety of teaching methodologies, including lecture, discussion, interactive activities, case studies, care maps, and evidence-based practice. Clinical experiences have traditionally been consistent with those discussed in the literature. The traditional clinical experience is instructor led and hospital based in acute care settings, where students engage in the care of patients under the direct supervision of a nurse or a faculty member. Students also attend observation days in hospital ancillary areas, such as the operating room (OR), emergency department (ED), ambulatory care, Postanesthesia Care Unit (PACU), and Intensive Care Unit (ICU).
Clinical groups consist of 10 students per instructor; however, the number of students in any area or experience is allocated by the clinical instructor according to facility guidelines, inpatient census, faculty discretion, and other scheduling logistics. The details of scheduling are unpredictable and no attempts were made to control for the number of students in clinical settings during this study, as this is a constantly changing variable each semester (and within semesters).
Population and Sample
A convenience sample of 208 third-semester undergraduate baccalaureate nursing students enrolled in a pediatric nursing course in a southwestern university was studied. All students were enrolled in the course and in a clinical section as per the usual university procedures. To control for the individual student abilities and knowledge variable, clinical sections were randomly assigned to one of three clinical types—traditional clinical group, hybrid clinical group, or nontraditional clinical group. Institutional review board approval was received prior to commencement of this study. The Table shows sample clinical schedules for each clinical type.
Table: Sample Clinical Schedule for the Traditional, Hybrid, and Nontraditional Clinical Groups
The traditional clinical group consisted of a majority of clinical learning experiences occurring in a hospital inpatient unit. Students in this group spent six 8-hour clinical days in the inpatient unit and two 8-hour clinical days in hospital alternate experiences (e.g., ED, ICU). The total inpatient hours were 48; total alternate hours were 16. Because this was the traditional method of conducting clinical education in past semesters, this group was considered the control group.
The hybrid clinical group consisted of a blend of inpatient experiences and alternate experiences, both in and out of the hospital. The hybrid group spent four 8-hour clinical days in the inpatient unit and 32 hours in alternate experiences, both in and out of the hospital (e.g., Special Olympics competition event, clinics, ED, OR). The hybrid group students received 32 hours of inpatient experience and 32 hours total alternate hours.
The nontraditional clinical group consisted of a majority of clinical learning experiences occurring out of the hospital in-patient unit. Students in this group spent two 8-hour clinical days in the inpatient unit, for a total of 16 hours of inpatient experience. An additional 48 clinical hours included alternate activities, both in and out of the hospital, including camp, Special Olympics competition, clinics, and others. Total inpatient hours were 16; total alternate hours were 48.
Baseline Clinical Experiences Common to All Clinical Groups
All students completed a total of 90 clinical hours. A basis of 26 clinical hours (of the total 90 hours) was provided to all students, which included:
- Interactive laboratory experiences focusing on medication administration; skills, such as gastrostomy feeding and patient weights; pediatric physical assessment; and growth and development concepts.
- A major teaching project that consisted of planning, developing, and implementing a health promotion teaching event for children of various ages.
- Simulation laboratories offered throughout the semester, which focused on clinical reasoning and prioritization skills and incorporating concepts from class or clinical experiences.
Description of Alternate Experiences
Alternate experiences varied from observation only to hands-on, as described below. All alternate experiences required students to complete a journaling activity that tied growth and development theory and assessment to their observations to ensure that student learning was not passive.
In-Hospital Experiences. All in-hospital alternate experiences were observation-only experiences. On occasion, a student was allowed to perform limited skills under the direct supervision of the clinical nurse working with the student that day. In-hospital alternate experiences included areas such as the OR, ED, PACU, ICU, ambulatory care clinics, and specialty units, such as Hematology–Oncology.
Out-of-Hospital Experiences. These experiences ranged from observation only to hands-on and interactive, depending on the setting, such as:
- Special Olympics. Students engaged in various experiences at sporting events, including working the first aid station at bowling tournaments, providing basic first aid to children of various developmental stages, and directing–coordinating children in activities.
- Special needs family camp. Students spent a weekend with families of children with chronic illnesses. Students were paired with a family and spent the weekend engaging in all activities with the family; they learned about the child’s illness, the family dynamics and roles, and how to interact with all the children of the family and other families, caring for the children while their parents were attending support groups, and engaging in affective learning unique to this experience.
- Early childhood education. Students observed the children’s growth and development and interacted with children of various ages and stages in multiple venues. Interacting with children in classrooms provided students with nonthreatening opportunities to observe and apply concepts of growth and development and developmentally appropriate communication techniques. Activities where students observed children in their natural environments (e.g., playgrounds, churches, stores) allowed for further observation outside the clinical setting. Health screenings were conducted, allowing students to practice skills such as fingersticks, taking of vital signs and height and weight measurements, and performing vision and hearing screenings.
- Community clinics, schools, and immunization clinics. Students observed growth and development and physical assessments. Students participated in administering immunizations.
Evaluation consisted of clinical paperwork and student clinical performance via the usual clinical grading criteria, performance-based decision-making modules, students’ course evaluations, and the HESI™ Pediatric Specialty Examination. The HESI testing is a computerized standardized test provided and monitored by Health Education Systems, Inc., to evaluate nursing students’ comprehension of content. Clinical paperwork consisted of students’ description of the patients’ disease processes, growth and development, diagnostics, medications, patient needs, nursing care, and documentation. Simulation scenarios were modified from METI® pediatric standardized scenarios to evaluate the students’ thought processes, ability to prioritize, use of critical thinking, and ability to apply knowledge to clinical situations. A clinical reasoning tool was created by adapting scenarios from Baldwin’s (2007) article, “Friday Night in the Pediatric Emergency Department: A Simulated Exercise to Promote Clinical Reasoning in the Classroom.” Students were provided with a patient scenario and were asked to write specific step-by-step actions. The pediatric HESI examination was added for the evaluation purposes of this study. Students took the HESI examination and the course comprehensive examination and were allowed to use the higher grade as their final examination grade for the course. A pretest design was not used. The traditional clinical group served as the control group, and the student groups were randomized to control for individual student abilities and knowledge.
In the Senior II semester (students’ final semester prior to graduation), all students are required to take a comprehensive end-of-program HESI examination (End-HESI) as a general guide of their capstone knowledge. The pediatric subscale scores were also obtained for these cohorts as a liberal judge of students’ knowledge retention following the child health course.
The Clinical Reasoning Tool (Baldwin, 2007) was examined for content validation by a panel of expert pediatric nurses from general pediatrics, the pediatric ED, and academia. Priority rankings, interventions, and assessment data were also content validated and compared for interrater reliability. The Clinical Reasoning Tool could produce a total possible score of 240 points (10 points per patient per stage).
The HESI standardized examination was content correlated to the information in the course through the administration of a course-specific final examination. Student evaluations included questions about student perception of confidence and comfort in a variety of areas, was ranked on a 4-point Likert scale, and had open-ended comment questions. Pediatric subscores of the End-HESI scores were also evaluated to examine knowledge retention of the study participants.
Clinical reasoning skills were evaluated using the Clinical Reasoning Tool. The tool was divided into four stages presented in an unfolding progression, with each stage consisting of six pediatric cases divided into four stages of progress (Baldwin, 2007). Students were given 15 minutes to read through one stage and record their impressions of each child’s priority problem (or diagnosis), the assessment data (other information) needed, and the interventions they would use, ranking them from 1 = highest priority to 6 = lowest priority. Students were scored based on the accuracy and completeness of their answers, the comprehensiveness of their answers, and the priority rankings. A score of 0 to 2 points was given for each answer element per patient in each stage. Students scored higher points for more accurate answers. Figure 1 shows an example of one patient scenario through the four stages of progression, with a sample student answer and the corresponding points for the student’s responses. HESI raw scores were used to record student knowledge. Student course evaluations were recorded on a 4-point Likert scale and were averaged for each question. Student comments were examined for recurrent themes.
Figure 1. Sample Clinical Reasoning Tool scenario with sample student answers and sample scores. Student answers were given a score of 0 to 2, with higher points denoting more accurate answers. The numbers in the left column are the priority ranks (1 = highest priority, 6 = lowest priority) of the patient assigned by the student for each scenario. Note. I&O = intake and output; CHF = congestive heart failure; EKG = electrocardiogram; lytes = electrolytes; ARF = acute renal failure; AGN = acute glomerulonephritis; VS = vital signs.
A total of 208 participants were included in this study, which was conducted over two semesters. The majority of students were women, aged 20 to 30 years. The mean clinical reasoning score for all participants was 150.38. The mean HESI score was 891.64. Nursing program entrance examination scores averaged 73 (of a possible 100), and the average entrance grade point average was 3.94.
Overall, there were no statistically significant differences among groups in either clinical reasoning or HESI knowledge scores. Figure 2 shows clinical reasoning scores for the three groups. Clinical reasoning scores ranged from 56 to 199. The average score was 156.1 for the traditional group, 154.1 for the nontraditional group, and 148.4 for the hybrid group. Average HESI scores were 887.32 for the traditional group, 884.86 for the nontraditional group, and 908.09 for the hybrid group (Figure 3). HESI scores ranged from 554 to 1,226 (maximum score is 1,500).
Figure 2. Clinical reasoning scores for the traditional, nontraditional, and hybrid groups.
Figure 3. Average HESI examination knowledge scores for the traditional, nontraditional, and hybrid groups.
The end-of-program comprehensive HESI results provide students with a general consensus of their overall knowledge gained during the nursing program. Subscales divided by specialty area provide a snapshot of the accumulated knowledge in that subject. End-HESI Pediatric subscale scores for the students in this study averaged 941.33, which increased from End-HESI Pediatric subscale scores of 882.67 prior to study implementation (Figure 4). Students who were in the nursing program before the study was implemented attended the clinical experience in a manner similar to the traditional study group.
Figure 4. End-HESI examination Pediatric subscale scores.
Figure 5 shows the average scores of the students’ course evaluations (a total of 153 evaluations were completed). Significant differences were found among groups for two questions. Average scores for student comfort with learning pediatric concepts were high, at just above a 3 for all three groups. Students in all three groups strongly agreed that the clinical opportunities were beneficial to learning. Students in all groups also reported feeling comfortable interacting with children (average scores of 3.1 to 3.5). When students were asked how comfortable they were assessing children, the traditional group reported the highest level of comfort at 3.4. The nontraditional group rated assessment comfort the lowest at 2.9, and the hybrid group reported a score of 3. These differences were statistically significant between the traditional group and both the nontraditional and hybrid groups (p = 0.009 and p = 0.055, respectively). Students were asked to rate their time spent in the inpatient setting. The traditional group strongly agreed that they had “just the right amount of time,” reporting a score of 3. The hybrid group agreed, with an average score of 2.7. The nontraditional group rated their satisfaction with the time in the inpatient area as only a score of 1.7. These results were statistically significant between the nontraditional group and both the traditional and hybrid groups (p = 0.000 and p = 0.000, respectively).
Figure 5. Average student course evaluation scores. The asterisks indicate statistical significance for each group (p = 0.009, p = 0.055, and p = 0.000, respectively).
No correlations were noted for clinical reasoning or HESI scores for age, gender, or students who speak English as a second language. No correlations were found between clinical reasoning scores and HESI scores, entrance examination scores, or grade point average. A correlation was noted between HESI scores and nursing program entrance examination scores (p = 0.000).
Results from this study indicate that students gaining pediatric clinical experience in alternate settings can perform as well as students receiving experiences solely in the hospital setting. Students attending clinical experiences in varied settings were able to demonstrate similar clinical reasoning, prioritization, and assessment abilities. One of the concerns industry leaders express about today’s new graduate nurses is that they may not be able to prioritize and apply safe clinical judgment, especially if they do not spend adequate clinical time in inpatient units (Berkow et al., 2009; Del Bueno, 2005). The results of our study indicate that clinical experiences outside the hospital setting can provide students with opportunities to develop prioritization and clinical reasoning skills. Although no pretest studies were conducted to determine prior knowledge and abilities, our study demonstrates that the configuration of clinical learning opportunities can include a significant amount of alternate experiences without jeopardizing student learning outcomes. However, this does not imply that acute care or hospital-based clinical learning is not necessary or valuable. The realities of teaching in today’s health care environment dictate the need to expand the clinical experience beyond the traditional hospital setting. This study points to the possibilities that exist to promote student learning.
Knowledge scores among participants in the three groups were not statistically significant. The highest scores were recorded by the hybrid group, which might indicate that a variety of learning settings and experiences could enhance learning. In addition, these results tend to demonstrate that the pediatric clinical setting does not significantly affect student knowledge scores.
End-HESI Pediatric subscale scores (tested in the students’ final semester) increased after the study, compared with student cohorts in semesters prior to the study, which indicates that students’ knowledge retention could have been promoted by the methods implemented in this study. In addition to the coordination of clinical settings and assignments, other methodologies were initiated; therefore, it is not possible to correlate the End-HESI Pediatric subscale scores directly to the study itself. However, laboratory, simulation, and other focused activities implemented, along with the clinical site changes, have had positive effects as a whole.
Overall, students were positive about their clinical learning experiences and their learning outcomes. Students in the non-traditional group did express a desire for more inpatient clinical time, although their comments indicated they did not want to sacrifice the alternate experiences to obtain more inpatient time. Many students commented that “one more day on the unit would be nice.” In contrast, students in the traditional group strongly agreed that they had “just enough time on the inpatient unit,” yet many commented they would rather have “1 or 2 days less on the unit” and “more time in other settings.”
The biggest area of significant difference among groups was students’ comfort with their ability to assess pediatric patients. The students in the traditional group reported feeling the most comfortable with their assessment abilities, whereas the non-traditional group reported the least comfort with assessment. Logically, this indicates that students in the hospital setting had increased opportunities to perform physical assessments in acute care settings compared with settings outside of the hospital. One way for educators to address this challenge is to concentrate their efforts in finding appropriate alternative settings that will provide students with opportunities to practice assessment skills, such as physician offices, community clinics, and urgent care centers. Alternate learning opportunities need to be structured in a way that would require students to focus on assessment skills.
A limitation to the study was the lack of a pretest to evaluate students’ previous knowledge and ability. Instructor preference or bias toward clinical teaching methods may have affected clinical experiences or student satisfaction. Students’ preconceived perceptions of nursing as a hospital-based profession may have influenced their input regarding their clinical experience. Also, student groups were assigned in a block of three clinical courses, which may have interfered with scheduling to avoid conflicts with other courses. Finally, the participants in this study were fairly homogenous in regard to gender, age, and geographical area.
Implications for Nursing Education
The findings of this study can help educators to better plan clinical experiences, as well as to have confidence they are providing their students with quality learning opportunities that will produce the outcomes desired. Because nursing programs are experiencing difficulties finding adequate inpatient clinical sites, the study findings will allow educators to expand learning opportunities for students. Knowing that students can learn pertinent concepts in a variety of settings, nurse educators can more effectively use an array of settings to optimize clinical learning. Our study shows that pediatric nursing is well taught by using sources outside of the traditional hospital setting. In addition, the study provides support for nurse educators to expand pediatric clinical experiences to a variety of settings, rather than relying solely on traditional hospital-based methods.
More research is needed to determine whether these methods would yield similar results in other specialty areas and in other types of nursing programs. Recreating this study in a nursing program with fewer or limited clinical hours would be beneficial to determine its applicability in those circumstances, as well as for schools that lack access to pediatric hospitals or acute care pediatric populations. Integrating clinical reasoning activities strategically throughout the course to promote the development of reasoning skills and retention of critical content would also be beneficial.
In Educating Nurses: A Call for Radical Transformation, Benner, Sutphen, Leonard, and Day (2009) recommended broadening the clinical experience. According to Benner et al., half of all nurses work outside the hospital setting, and in today’s economic decline, more of the pediatric population is found in the community and schools than in the inpatient setting. As such, nursing students are more likely to encounter children in settings outside the hospital than in traditional in-patient settings. Our study provides a basis for expanding the pediatric clinical experience beyond the traditional inpatient model to multiple community clinical experiences. The results of this study indicate that student knowledge and clinical reasoning can be developed using clinical experiences outside the hospital just as well as using in-hospital settings. As pointed out by Gubrud-Howe and Schoessler (2008), clinical experiences do not need to be contained in the hospital setting, but they do need to be structured, and learning should be planned rather than random.
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Sample Clinical Schedule for the Traditional, Hybrid, and Nontraditional Clinical Groups
|Sample Clinical Schedule by Teaching Type|
|Clinical Group||Inpatient Hours||Alternate Hours|
|Sample Schedule by Group, Date, and Place of Clinical Experience|
| Student A||9/2||Inpatient|
| Student B||9/2||Inpatient|
| Student C||9/2||Inpatient|
|9/13 to 9/15||Camp|