Journal of Nursing Education

Research Briefs 

Beyond the Dedicated Education Unit: Using Cognitive Load Theory to Guide Clinical Placement

Pamela McPhie Mulcock, MSN, RN; Jane Grassley, PhD, RN, IBCLC; Michael Davis, BSN, RN; Kathryn White, BSN, RN

Abstract

Background:

Navigating multiple instructors and clinical agencies can impair students' learning by increasing their cognitive load and perceived stress. This study used cognitive load theory to guide the home base clinical model (HBCM), which assigned students to the same faculty and hospital unit for two consecutive medical–surgical clinical courses.

Method:

The study used a quasi-experimental three-group design to evaluate the effects of the HBCM on students' perceived stress, compared with groups who changed hospital or instructor. A 10-point visual analog scale measured students' perceived stress on nine clinical tasks.

Results:

The study recruited 140 participants. Reductions in mean stress were greater for the HBCM groups than the other two groups.

Conclusion:

The study findings challenge the current practice of placing students with changing faculty and facilities. The HBCM demonstrates potential as an effective model for increasing students' ability to learn by decreasing their cognitive load and subsequent stress in their clinical placements. [J Nurs Educ. 2017;56(2):105–109.]

Abstract

Background:

Navigating multiple instructors and clinical agencies can impair students' learning by increasing their cognitive load and perceived stress. This study used cognitive load theory to guide the home base clinical model (HBCM), which assigned students to the same faculty and hospital unit for two consecutive medical–surgical clinical courses.

Method:

The study used a quasi-experimental three-group design to evaluate the effects of the HBCM on students' perceived stress, compared with groups who changed hospital or instructor. A 10-point visual analog scale measured students' perceived stress on nine clinical tasks.

Results:

The study recruited 140 participants. Reductions in mean stress were greater for the HBCM groups than the other two groups.

Conclusion:

The study findings challenge the current practice of placing students with changing faculty and facilities. The HBCM demonstrates potential as an effective model for increasing students' ability to learn by decreasing their cognitive load and subsequent stress in their clinical placements. [J Nurs Educ. 2017;56(2):105–109.]

Clinical placements are a major source of stress for students during their prelicensure nursing education. Cooper, Courtney-Pratt, and Fitzgerald (2015) found clinical placement in nursing education “to be the most important but also the most stress-inducing component” (p. 1004) of students' learning. This stress can impede students' learning and performance in their clinical placements (Beddoe & Murphy, 2004). Developing clinical placement models that can lower student stress is imperative. One potential model is the home base clinical model (HBCM), the basis of which was discovered by the author (P.M.M.) during a serendipitous change to her clinical teaching assignments. Although the author generally taught the first semester of two medical–surgical acute care clinical courses, her clinical course assignment changed to the second course in a subsequent semester. Eight of the 10 students from the first semester chose to be in the second semester clinical group in the same hospital unit. The instructor was concerned about lost opportunities for these students to see different units, types of patients, nurses, and teaching styles. The only benefit anticipated by this repeat placement was an easier transition, because students were already oriented to the hospital unit. In actuality, the students reported substantial decreases in their stress levels and an equally substantial increase in their confidence related to providing client care.

With these students' positive response to their clinical placement experience in mind, a pilot study was conducted to replicate and evaluate this model. The purpose of the study was to determine whether students assigned to the same hospital unit with the same nursing faculty for two consecutive medical–surgical acute care clinical courses would report greater reductions in levels of stress than students assigned to conventional clinical placements that included a change in hospital, instructor, or both. Cognitive load theory (CLT) was used as a framework for the study.

Background

The complexity and challenges of placing students in real clinical settings and students' subsequent stress have been well documented. A national survey of nursing faculty identified factors that contributed to students' perceptions of stress, including the size of clinical groups, time spent in facility orientation, and lack of quality sites for instruction. A significant number of survey participants ranked “the time-consuming nature of students learning multiple clinical agency systems” as a major barrier to optimal student clinical experiences and learning (Ironside, McNelis, & National League for Nursing, 2010). In addition, Ironside and McNelis (2010) stated “no strategies were identified by respondents as being very effective in addressing this barrier” (p. 14).

Many clinical placements are currently selected by facility availability, personal preference, or historical precedence. Roxburgh, Conlon, and Banks (2012) reported that clinical placements are most often rotational and “may be described as a series of placements that have no defined connection between them other than providing exposure to a range of patients” (p. 783). Rotational placement means students have to build relationships with a new group of nurses, successfully learn the new facility's layout, and gain functional competency with the different electronic charting programs, information technology, and electronic equipment with each course change (Cooper et al., 2015). Ongoing faculty changes contribute to students' stress and hinder the instructor's ability to know “the student nurses and their skills” and to help them relate to “the confusing stimuli-filled clinical learning environment” (Papp, Markkanen, & von Bonsdorff, 2003, p. 267). Levett-Jones, Lathlean, Higgins, and McMillan (2008) reported that students needed 2 to 4 weeks in a new clinical setting to settle in and confidently engage in learning. These findings suggest that many of the stressors and challenges experienced by students are a direct result of processing new environments and instructors. The resulting “high stress and anxiety impede concentration, memory, and problem-solving ability, which in turn adversely affects academic performance and learning” (Beddoe & Murphy, 2004, p. 305).

Applying the principles of CLT to clinical placement may help explain the less stressful, confidence-building experience reported by the initial eight students. CLT proposes that learning can be enhanced by instructional design strategies, which are based on the human cognitive architecture of working and long-term memory (Chen, Dore, Grierson, Hatala, & Norman, 2014). Working memory is the amount of mental resources an individual has available to learn new information at any given time. Although long-term memory has a limitless capacity for storing and retrieving information, working memory is limited to a relatively small amount of data or approximately 20 seconds of attention. Learning occurs when information is transferred from the working memory to long-term memory. This process is impaired when students are presented with too much new information in a short period of time; however, the amount of information, or cognitive load, can be modified by instructional design (Chen et al., 2014).

The two primary components of cognitive load are the intrinsic and extraneous cognitive load (Sweller, Ayres, & Kaluga, 2011). Intrinsic load involves the complexity, interactivity, and amount of essential information to be learned. A complex learning environment, such as the clinical setting, increases intrinsic cognitive load (Chen et al., 2014). For example, when students begin a new clinical placement, they are confronted with an enormous amount of new information that includes orienting to the hospital unit, as well as practicing their novice patient care skills (Chen et al., 2014). Extraneous load, the second component, involves the mental effort required to process information that is not necessary to achieve mastery of the primary learning objective (Sweller, Ayres, & Kalyuga, 2011). It can be attributed to instructional strategies that pose a burden on students' cognition (Chen et al., 2014). For example, teaching students how to chart correctly is essential, while having students learn multiple charting programs adds unnecessary cognitive load.

When the total amount of information to be learned, (i.e., the combination of intrinsic and extraneous cognitive load) exceeds working memory capacity, cognitive overload occurs. This overload leads to decreased learning and stress (Chen et al., 2014). Stress has been identified as a manifestation of cognitive overload that has “the potential of exceeding coping resources” (Evans & Cohen, 1987, p. 571). Although intrinsic load cannot be altered without eliminating essential information, extraneous load can be decreased through instructional design. The HBCM may be an example of a strategy that can lower extraneous cognitive load as evidenced by the decrease in stress reported by the original eight students. Students were able to concentrate on developing their patient care skills rather than having to focus on learning a new hospital environment (Hessler & Henderson, 2013; Paas & Sweller, 2012). Therefore, CLT may be a useful framework to guide clinical placements.

Method

This study was conducted using a quasi-experimental three-group posttest design. All students surveyed attended the same public university baccalaureate nursing program in the Mountain West. Students were all assigned to acute care medical–surgical units during the second and third semesters of their five-semester nursing program. The convenience sample of students represented four possible configurations of clinical groupings: a change of instructor from the first to subsequent second semester (CI), a change of instructor and facility at the semester change (CICF), a change in facility at the semester change (CF), and no change in instructor or facility for two subsequent semesters (HBCM). The potential for a CF group was not studied, as it was found impractical due to faculty resistance and available facility sites.

Direct measurement tools of cognitive load in clinical settings were not available at the time of the study (i.e., 2012 to 2013). Consequently, stress was chosen as the measurement because it had been identified as a manifestation of cognitive overload (Evans & Cohen, 1987). A researcher-generated survey was developed from the literature and validated by a group senior nursing students. Nine clinical tasks were identified as potential sources of students' stress. These nine items were grouped by patient care responsibilities (e.g., charting patient information, accessing medical information about assigned patients, using medical equipment and materials, caring for patients and their families), unit issues (e.g., working with nursing staff and understanding their expectations, following unit protocols and scheduled routines), faculty expectations (e.g., understanding and meeting instructor expectations and understanding clinical assignments), and peer relationships (e.g., working with other students). Students were asked to rate each item as to their level of stress in the transition from the first to the second medical–surgical acute care clinical courses using a 10-point visual analog scale (1 = no stress to 10 = extremely stressful). The survey tool also included eight demographics questions.

Data collection began in spring 2012 after the university institutional ethics review board approved the study. Students were recruited from three student cohorts. Participating students completed the paper-and-pencil study survey. Demographic data were summarized by group counts and percentages. Responses on the nine visual analog scale items were calculated using descriptive statistics. The group means on each of the nine items were analyzed with ANOVA and ANCOVA to determine whether students assigned to the HBCM reported a significant reduction in their stress levels in the transition from the two clinical courses, compared with students assigned to the CI and CICF groups.

Results

Of the 192 students recruited to participate in the study, 73% (N = 140) completed the survey. This convenience sample consisted primarily of White (88%) women (80%), age 18 to 34 years (73%). The majority had additional stressors, such as outside employment (70%, of which 12% worked full time) or responsibility as a primary caregiver, for at least one person outside of school or work (55%). Thirty-four participants (24%) had the same instructor and same facility (HBCM) for their beginning and advanced medical–surgical courses. Fifty-seven participants (41%) had different instructors but the same facility (CI) and 49 participants (35%) had different instructors and different facilities (CICF) (Table 1).


Demographics for 140 Participants in the Home Base Survey

Table 1:

Demographics for 140 Participants in the Home Base Survey

The HBCM groups reported greater reductions in mean stress on the each of the nine items, compared with the other two groups (Table 2). When compared with a change in instructor, but not facility (CI), the reduction in stress was significantly greater in the HBCM for using medical equipment and material (p = .03), caring for patients (p = .01), working with nursing staff and understanding their expectations (p = .01), and following unit protocols (p = .01). The contrast was more significant when both the instructor and facility changed (CICF). When compared with the CICF group, the HBCM group had significantly greater reductions in all types of stress with the exception of working with peers (p = .09). These significant differences between the HBCM group and the other two groups did not change with adjustments for gender, age group, ethnicity, employment, and caregiver status as covariates. When the CICF and CI groups were compared, the only significant difference in stress reduction was charting patient information (p = .05). Adjusting for the covariates produced a change in significance for accessing medical information about assigned patients (p = .12 to p = .05) (Table 2).


Comparison of Student Groups by Mean Change in Student Ratings of Stress Levels in Nursing Clinical Placements

Table 2:

Comparison of Student Groups by Mean Change in Student Ratings of Stress Levels in Nursing Clinical Placements

Discussion

CLT supports these results. There were significant differences in reduction of stress between the HBCM group and the other groups, specifically in items related to learning the facility (e.g., using medical equipment and material, caring for patients, working with nursing staff and understanding their expectations, and following unit protocols). These findings suggest that learning a new facility increases students' extraneous cognitive load (Hessler & Henderson, 2013) and is a major source of stress for students as reported in the literature (Del Prato, Bankert, Grust, & Joseph, 2011). Therefore, placing students in the same facility for consecutive semesters of medical–surgical nursing clinical courses can increase students' capacity to learn by reducing their total cognitive load (Jackson & Farzaneh, 2012). Use of the HBCM places students in familiar clinical settings, allowing them to focus on developing their nursing skills and providing patient care (e.g., intrinsic load), rather than new environmental factors (e.g., extraneous load), such as unit protocols, computer charting systems, location of equipment, and nursing staff (Hessler & Henderson, 2013; Paas & Sweller, 2012).

The small sample of students from the same university could limit applicability to other settings. A second limitation is that two sister units of one hospital were used as a home base. It is indeterminate whether the reduction of stress was from the specific units or whether the same results could be replicated on other hospital units. Clinical placement in a designated educational unit where students worked with the same nurse for every shift may have affected some students' survey responses, lowering reported stress in the CI and CICF groups.

Implications

The pilot study results suggest that the HBCM can facilitate positive learning experiences in clinical placements by decreasing students' cognitive load and subsequent stress. With the implementation of this model, clinical instructors would already be cognizant of their students' clinical skills at the beginning of subsequent clinical courses, allowing them to tailor instruction based on individual student needs. As academic institutions struggle to find hospital placements and, out of necessity, replace hospital days with simulation, using the HBCM may help schools maximize their in-hospital clinical time. In addition, implementation of the model did not require finding more placement spots; it simply kept students in the same sites and had current instructors change courses. The HBCM could benefit clinical partners by decreasing the number of new students needing orientation each semester. Staff nurses would become familiar with the students placed in their unit and spend less of their time assessing students' abilities, which may facilitate mentoring and foster student autonomy.

To address the study's limitations and strengthen the evidence supporting the HBCM as an effective clinical placement model, the study should be replicated with other clinical sites and instructors. Further evaluation of the study survey is needed to address the gap in tools specific to nursing education that measure cognitive load (Chen et al., 2014; Hessler & Henderson, 2013).

Conclusion

Nursing students must master a monumental amount of information to navigate the complex clinical environment. The findings of this study challenge the current practice of placing students with a variety of faculty and facilities. Guided by CLT, the HBCM demonstrates potential as an effective model for increasing students' ability to learn by decreasing their cognitive load and subsequent stress in their clinical placements. Students in this environment are then able to gain a depth, rather than breadth, of understanding in patient care.

References

  • Beddoe, A. & Murphy, S. (2004). Does mindfulness decrease stress and foster empathy among nursing students?Journal of Nursing Education, 43, 305–312.
  • Chen, R., Dore, K., Grierson, L.E.M., Hatala, R. & Norman, G. (2014). Cognitive load theory: Implications for nursing education and research. Canadian Journal of Nursing Research, 46(2), 28–41.
  • Cooper, J., Courtney-Pratt, H. & Fitzgerald, M. (2015). Key influences identified by first year undergraduate nursing students as impacting on the quality of clinical placement: A qualitative study. Nurse Education Today, 35, 1004–1008. doi:10.1016/j.nedt.2015.03.009 [CrossRef]
  • Del Prato, D., Bankert, E., Grust, P. & Joseph, J. (2011). Transforming nursing education: A review of stressors and strategies that support students' professional socialization. Advances in Medical Education and Practice, 2, 109–116. doi:10.2147/AMEP.S18359 [CrossRef]
  • Evans, G.W. & Cohen, S. (1987). Environmental stress. In Stokol, D. & Altman, I. (Eds.), Handbook of environmental psychology (Vol. 1, pp. 571–610). New York, NY: Wiley.
  • Hessler, K.L. & Henderson, A.M. (2013). Interactive learning research: Application of cognitive load theory to nursing education. International Journal of Nursing Education Scholarship, 10, 1–9. doi:10.1515/ijnes-2012-0029 [CrossRef]
  • Ironside, P.M. & McNelis, A.M., National League for Nursing. (2010). Clinical education in prelicensure nursing programs: Results from a NLN national survey, 2009. New York, NY: National League for Nursing.
  • Jackson, T.W. & Farzaneh, P. (2012). Theory-based model of factors affecting information overload. International Journal of Information Management, 32, 523–532. doi:10.1016/j.ijinfomgt.2012.04.006 [CrossRef]
  • Levett-Jones, T., Lathlean, J., Higgins, I. & McMillan, M. (2008). The duration of clinical placements: A key influence on nursing students' experience of belongingness. Australian Journal of Advanced Nursing, 26 (2), 8–16.
  • Paas, F. & Sweller, J. (2012). An evolutionary upgrade of cognitive load theory: Using the human motor system and collaboration to support the learning of complex cognitive tasks. Educational Psychology Review, 24, 27–45. doi:10.1007/s10648-011-9179-2 [CrossRef]
  • Papp, I., Markkanen, M. & von Bonsdorff, M. (2003). Clinical environment as a learning environment: Student nurses' perceptions concerning clinical learning experiences. Nurse Education Today, 23, 262–268. doi:10.1016/S0260-6917(02)00185-5 [CrossRef]
  • Roxburgh, M., Conlon, M. & Banks, D. (2012). Evaluating the hub and spoke models of practice learning in Scotland: A multiple case study approach. Nurse Education Today, 32, 782–789. doi:10.1016/j.nedt.2012.05.004 [CrossRef]
  • Sweller, J., Ayres, P. & Kalyuga, S. (2011). Cognitive load theory. New York, NY: Springer. doi:10.1007/978-1-4419-8126-4 [CrossRef]

Demographics for 140 Participants in the Home Base Survey

Demographicn%SD
Gender
  Female112803.4
  Male28203.4
Age group (years)
  18 to 245337.94.1
  25 to 3449354.0
  35 to 442719.33.3
  45 to 5485.72.0
  55 to 6432.11.2
Ethnicity
  White10172.13.8
  Hispanic or Latino128.62.4
  Asian/Pacific Islander42.91.4
  Native American or American Indian10.70.7
  Other10.70.7
Employment
  Full time1712.12.8
  Part time8359.34.2
  Not employed4028.63.8
Caregiver statusa
  Yes7554.74.3
  No6245.34.3
Student group
  Same instructor, same facility3424.33.6
  Different instructor, same facility5740.74.2
  Different instructor, different facility49354.0
Worked at facility prior to course
  Yes for NURS33396.42.1
    Same instructor, same facility21.41.0
    Different instructor, same facility53.61.6
    Different instructor, different facility21.41.0
  Yes for NURS343b1913.72.9
    Same instructor, same facility42.91.4
    Different instructor, same facility85.82.0
    Different instructor, different facility751.9

Comparison of Student Groups by Mean Change in Student Ratings of Stress Levels in Nursing Clinical Placements

Source of StressGroup Differences in Mean Changea

NC-CIpNC-CICFpCI-CICFp
Charting patient information−0.7.13−1.6.01−0.9.05
Accessing medical information about assigned patients−1.0.06−1.7.01−0.7.12
Using medical equipment and materials−0.9.03−1.1.01−0.1.70
Working with nursing staff and understanding their expectations−1.3.02−1.4.01−0.2.73
Following unit protocols and scheduled routines−1.2.01−1.7.01−0.5.27
Caring for patients and their families−1.1.01−1.3.01−0.2.50
Understanding and meeting instructor expectations−1.0.07−1.1.05−0.1.76
Understanding clinical assignments and homework−0.8.12−1.3.01−0.5.28
Working with other students in your clinical group−0.7.06−0.6.090.1.86
Authors

Ms. Mulcock is Undergraduate Clinical Coordinator, Dr. Grassley is Professor and Jody DeMeyer Endowed Chair School of Nursing, Boise State University; Mr. Davis is Registered Nurse, St. Luke's Boise Medical Center, Boise; and Ms. White is Support Nurse, Lincoln Junior High School, Skokie, Idaho.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Dr. Ann Hubbert and Dr. Suzan Kardon-Edgren for their support of the home base clinical model study.

Address correspondence to Pamela McPhie Mulcock, MSN, RN, Undergraduate Clinical Coordinator, School of Nursing, Boise State University, 1910 University Drive, MS – 1840, Boise, ID 83725; e-mail: pamelamulcock@boisestate.edu.

Received: May 18, 2016
Accepted: September 27, 2016

10.3928/01484834-20170123-07

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