Nursing students need to be able to link theory to practice in their clinical experiences. Use of relevant and appropriate questions is fundamental to having students reflect on and analyze their clinical practice experiences (Myrick & Yonge, 2002; Oermann, 2008). The postconference provides an opportunity for the clinical instructor to ask the right questions and encourage reflection. A postconference takes place at the end of the clinical day and is designed for each student in the group to discuss their practice experiences (Letizia & Jennrich, 1998; Yehle & Royal, 2010). Student learning and connections to theory can be enhanced during postconference by asking high-level questions that require students to think critically and to promote collaborative work with their peers (Hsu, 2007; Oermann, 2008; Wink, 1995). Without structure to the postconference, the focus and manner in which the discussion is facilitated varies among clinical instructors. Given this diversity, it can be unclear whether students have been provided with equal opportunity to integrate theoretical concepts from the classroom into the clinical setting. Thus, it is imperative that instructors optimize this time to integrate an effective teaching strategy that fosters critical thinking and clinical judgment.
Postconferences should be intentionally planned to foster student learning related to the course goals and objectives (Oermann, 2008). Considerable variability can exist in the ability to foster this learning, particularly if there is wide diversity in the clinical instructors’ skills and experiences. In the author’s setting, many of the clinical instructors were sessional or part time, and many were novices in this role. Given this, it became a challenge to ensure that classroom theory was consistently related to the practice setting. As one of the coordinators responsible for overseeing the second-year clinical course, clinical instructors frequently sought feedback for strategies to assist students with integrating theory into the practice setting. As such, it became clear that students’ postconference experiences were distinctly different. Eliminating variation in the process and standardization of practice improves outcomes and supports quality nursing care (American College of Obstetricians and Gynecologists, 2012; International Organization for Standardization, 2008; Kobs, 2006). The author therefore implemented the use of guided questions during postconference as a modality to synthesize and integrate theoretical knowledge into the clinical practice area. Standardizing the clinical postconference by integrating thought-provoking questions was implemented to address this inconsistency, support clinical instructors with their teaching, and enhance student learning.
This approach (i.e., the use of guided questions) to teaching was meant to assist clinical instructors with creating a consistent space for students to engage with others, challenge thoughts, and make experiences meaningful. Ironside’s (2006) research reinforces the importance of moving beyond conventional pedagogies and focusing on innovative teaching strategies that help students challenge their assumptions and interpret situations from multiple perspectives. The development and implementation of preplanned questions was chosen as a practical approach for clinical instructors to challenge students’ thinking. The purpose of this article is to review the integration of guided questions in postconference and their potential use in other clinical settings.
Standardizing Clinical Postconference With Guided Questions
Development of the Guided Questions
The guided questions in postconference were implemented with approximately 18 groups of second-year students who were registered in a 4-year baccalaureate nursing program at a Canadian university. Each group consisted of approximately eight students, with one clinical instructor. The students provided care to adult patients in acute care settings during two day or evening shifts in a row, and then participated in a weekly postconference facilitated by their clinical instructors. The 1-hour postconference occurred at the end of the second clinical shift. Students had the benefit of having completed required preparation for theory courses and then added a clinical context to the subject matter. This led to fulsome and rich discussions with peers.
Weekly open-ended questions were developed by the author and implemented within each postconference. The preplanned questions were communicated to students and clinical instructors in advance through the course syllabus. The questions related to the course material taught in the classroom 1 to 2 weeks prior to the clinical session. The clinical instructor of each student group initiated and facilitated discussion that correlated the students’ clinical experiences to specific content areas. The questions were open ended and allowed for personalization by the instructors to the students’ unique experiences.
A key component of linking theory to practice is an awareness of the nursing program curriculum. Knowledge of the students’ curriculum was important for the development and implementation of the guided questions. Specifically, it was crucial that relevant and appropriate content areas were embedded within the clinical course concurrent with the clinical experience at the right time. Thus, communication with appropriate classroom faculty teaching concurrent theory courses occurred weeks prior to the start of the clinical component. For example, in the first week of the second-year theory classes, nursing students spent time learning about the importance of listening to the patient narrative and the principles of medication administration. The following open-ended questions were therefore developed to guide discussion during the second week of postconference to integrate those concepts: “How did the patient’s narrative benefit you and the patient in the process of medication administration?” and “How did the patient’s narrative impact your physical and other determinants of health assessment?” These questions provided students with an opportunity to discuss their assigned patient’s lived experience and its relationship to safety, in the context of principles for medication administration.
Students were also expected to demonstrate evidence of reflective practice during their clinical time. Reflection requires connecting one’s actions with outcomes and knowing what occurred as a result of nursing actions (Tanner, 2006). Evidence of reflection for this course was demonstrated by students using various formats and was to be submitted to the clinical instructor twice throughout the semester. Pictorial representation, poetry, and concept maps were examples of the formats students selected to show insight from practice experiences. Students were required to use Tanner’s (2006) clinical judgment model to assist and guide them with reflective practice. One of the submissions, due midway through the semester, was to be based on a discussion that occurred from the preplanned questions in postconference. Essentially, students were to consider what aspect of clinical practice, in the context of one of the guided questions, resonated most and guided them to further exploration. Because the students had limited clinical experiences, they were given a focus for this first reflection on their practice. The second submission was due at the end of the rotation and required students to analyze numerous clinical examples. At that point, students were not expected to integrate guided postconference questions.
Preparation of Clinical Instructors
Several weeks prior to the start of the semester, clinical instructors participated in an orientation to the second-year clinical course. During this orientation, the objectives and strategies for initiating discussion of the preplanned questions were articulated. Their role during postconference was reinforced as that of a mentor and facilitator of the discussion, rather than a didactic teacher. The importance of adhering to the questions as strategically placed in the course syllabus was highlighted. Clinical instructors were provided with suggestions from the literature to assist them with facilitating their group discussions. These suggestions included taking the time to create an environment in which students were comfortable discussing concepts and ideas without fear (Gaberson & Oermann, 2010). In addition, the notions of ensuring that students were given sufficient opportunity to respond to questions, avoiding interruptions, and actively listening to responses were reinforced with the clinical instructors (Gaberson & Oermann, 2010).
The clinical instructors were responsible for arriving at each postconference prepared to initiate and facilitate discussions with their groups. They were provided with resources, including literature that students were required to read for their corequisite theory courses. Instructors were expected to integrate the literature into the discussions, making students accountable for learning that had occurred in the classroom and clinical settings. It should be noted that debriefing critical events that occurred during the clinical sessions were recognized to take priority over the preplanned question discussions. Because a formal time frame was not allotted for the discussion of questions, instructors could select to reflect and analyze other aspects of clinical practice with the student group. This was dependent on the needs and clinical experiences of students within the group.
An Example of Implementing a Structured Postconference
Postconference typically began by providing students with an opportunity to debrief their clinical day; the time frame for this varied among groups. The clinical instructor then shifted the focus to the guided postconference questions. One example of guided questions that deliberately related nursing ethics and alterations to the respiratory system was “Discuss the ethical values within the Code of Ethics for Registered Nurses which are most applicable to the care you provided to your patient this week? Discuss the ethical considerations in providing care to a patient with end-stage respiratory disease (e.g., chronic obstructive pulmonary disease? How might the ethical considerations vary with a patient receiving aggressive treatment versus end stage aspects of the disease?” In the postconference discussions facilitated by the author (who also taught the course), students were frequently challenged with defining the terms ethical values and ethical considerations. Their initial response to the question above would focus on the pathophysiology of chronic obstructive pulmonary disease. Ensuring a common and correct understanding of terminology was pertinent to advancing the discussion. The use of low-level questions served as a foundation for creating a common understanding of language and terminology. Low-level questions seek to identify and recall factual information (Profetto-McGrath, Bulmer Smith, Day, & Yonge, 2004). Given that the content was typically taught in the classroom 1 to 2 weeks prior to the postconference, initial questions that required students to simply recall information was advantageous. Examples of these questions included:
- What is meant by the terms ethical principles and ethical considerations?
- What are the physical and psychological manifestations of a patient with end-stage respiratory disease?
- Define the term aggressive treatment.
These types of questions were effective in clarifying confusion among students. When students had a clearer understanding of terminology and facts, they were able to advance their thinking and make connections to clinical practice.
The conversation with the clinical group progressed with the use of higher level probing questions of the cognitive taxonomy. High-level questions require the student to use cognitive skills related to analysis and synthesis (Profetto-McGrath et al., 2004). The goal at this point was to assist students with moving beyond superficial knowledge and consider hypothetical and complex ideas related to the area of focus. Examples of these types of questions used by the author included:
- How do you address the ethical consideration(s)?
- What is the impact of this situation to the patient and his or her family?
- What criteria do/did you use to determine whether a patient is receiving aggressive or end-stage treatment?
- What is the connection between the ethical consideration and the diagnosis?
- How would this situation differ if the patient lacked cognitive capacity?
- How does this compare to the care you provided to your patient this week?
High-level questions that involved probing and exploration required more thought and consideration by the students. These probing questions challenged students’ critical-thinking abilities and moved them beyond the simple recall of facts. The fulsome conversations that occurred with the high-level questions often took more time (typically 30 to 45 minutes) for students to analyze and make meaning. Research studies indicate that instructors typically ask nursing students low-level (recall) questions, rather than higher level, more challenging questions (Hsu, 2007; Oermann, 2008; Profetto-McGrath et al., 2004). Thus, being attentive to the type of questions posed to students during postconferences was crucial for students to make meaning of their clinical experiences. The inclusion and appropriateness of both low- and high-level questions must be considered when developing guided questions and facilitating postconference discussions.
Implications and Future Considerations
At the end of the semester, the coordinator and clinical instructors met to evaluate components of the course and sought feedback for future sessions. Discussions with the clinical instructors consistently reinforced the advantage of increased structure to clinical postconferences. Instructors verbalized that they had developed an increased awareness of this Canadian university’s nursing program curriculum. They were expected to demonstrate accountability in understanding best practice and current evidence in the content areas embedded within the curriculum. Novice instructors appreciated the structure and guidance with this aspect of their clinical teaching. They were comforted in knowing that the learning that occurred for students during postconference related to classroom teaching. Experienced instructors revealed an appreciation for not having a time frame allotted for the guided questions. This provided them with autonomy in selecting other topics specifically related to the students’ clinical practice area. Conversations that occurred from the guided questions provided an opportunity for clinical instructors to assess their own learning needs, as well as evaluate students’ critical thinking and knowledge gaps. Based on the feedback from instructors, standardization of postconference continues to occur in this particular clinical course. The guided questions have continually evolved each semester on the basis of the content addressed in the classroom. Further, the questions have been altered from the initial piloting of this teaching approach to reflect a higher level of the cognitive taxonomy.
The author recognizes the need and significance of conducting research to fully comprehend the effectiveness of standardizing postconferences with the use of questions for students in clinical practice. Research needs to focus on questioning clinical instructors in this course, relative to students’ level of critical reasoning and success in meeting course objectives. This is an area of educational practice the author would like to explore in the future.
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