Journal of Nursing Education

Research Briefs 

Progressive Dosing of Observed Real-Life Clinical Exposure for Nurse Practitioner Training

Imelda Reyes, DNP, MPH, RN, APRN-BC; Sharron Close, PhD, MS, RN, CPNP-PC, FAAN; Jeannie Rodriguez, PhD, RN, CPNP-PC; Dian Evans, PhD, FNP-BC, ENP-BC, FAANP

Abstract

Background:

In most advanced practice programs, preceptors are relied on for providing student clinical experiences. Preceptor feedback often indicates that many students show competency deficits in well child care, case presentation, and clinical skills.

Method:

An innovative preclinical experience was developed using nonscripted pediatric patient and family volunteers from the local community. During the three 4-hour experiences, students obtained a health history, performed a full physical examination, and presented their findings using a standardized case presentation format. Student anxiety and levels of confidence were assessed before and after each experience.

Results:

Student anxiety decreased, and self-confidence and clinical skill competencies improved. Students who participated in the experiences with faculty demonstrated improved entry-level competencies, compared with previous cohorts who had not received the intervention.

Conclusion:

Preclinical experiences using pediatric patients improved advanced practice nursing student confidence and competencies and reduced anxiety, improving overall entry-level clinical performance. [J Nurs Educ. 2017;56(9):552–555.]

Abstract

Background:

In most advanced practice programs, preceptors are relied on for providing student clinical experiences. Preceptor feedback often indicates that many students show competency deficits in well child care, case presentation, and clinical skills.

Method:

An innovative preclinical experience was developed using nonscripted pediatric patient and family volunteers from the local community. During the three 4-hour experiences, students obtained a health history, performed a full physical examination, and presented their findings using a standardized case presentation format. Student anxiety and levels of confidence were assessed before and after each experience.

Results:

Student anxiety decreased, and self-confidence and clinical skill competencies improved. Students who participated in the experiences with faculty demonstrated improved entry-level competencies, compared with previous cohorts who had not received the intervention.

Conclusion:

Preclinical experiences using pediatric patients improved advanced practice nursing student confidence and competencies and reduced anxiety, improving overall entry-level clinical performance. [J Nurs Educ. 2017;56(9):552–555.]

In advanced practice registered nurse (APRN) education, community- and hospital-based preceptors are relied on for providing clinical experiences. In academic programs with strong faculty practice opportunities, students often develop clinical competencies under the guidance of faculty preceptors. However, for programs that do not have clinical practice opportunities with faculty preceptors, community- and hospital-based preceptors are essential. To prepare students for entry into clinical experiences, faculty often rely on clinical simulation techniques, including the use of high-fidelity manikins, peer practice, or use of standardized patients (Schram & Mudd, 2015). These preclinical experiences can help students to gain competencies prior to entering community- and hospital-based settings where preceptors may be limited in the amount of time they can allocate toward preparatory training (Larue, Pepin, & Allard, 2015).

The purpose of this article is to describe an approach to improving student clinical competencies and readiness for community- and hospital-based clinical experiences through faculty-proctored preclinical experiences. These experiences were designed to provide students with an opportunity to practice well child assessment and case presentation skills. This teaching project was funded through an innovative teaching grant that provided funds for recruitment and compensation of children and parents to attend a preclinical experience for nurse practitioner students.

Background

In the first semester of the nurse practitioner program, a pediatric-specific advanced health assessment course is offered. This instructor for this course provides content on health assessment using a development approach, covering well child care from infancy through adolescence. A co-requisite course, titled Staying Healthy in Pediatrics, offers an introduction to the key topics of health and development from a wellness perspective. During the Staying Healthy course, the pediatric nurse practitioner (PNP) students obtain clinical hours focused on well child care. These hours are completed with community-based preceptors in primary care clinics. Preceptors often commented that students demonstrated fragmented recall and application of pediatric core knowledge. They reported that students entered the clinical experience with weak assessment skills that required early remediation by the preceptor. Students also reportedly lacked proficiency in case presentations. These factors, combined with student-reported anxiety in the clinical setting, revealed limitations and vulnerability in the students' preclinical preparation. This innovative teaching project was designed to provide students with preclinical training that represented real-life clinical situations to integrate core knowledge, clinical skills, and to reduce student anxiety.

The aims of this project were to:

  • Develop a faculty-supervised clinic environment where students could practice gathering histories, conducting physical examinations, and providing anticipatory guidance prior to entering their clinical rotation.
  • Evaluate student case presentation using the SNAPPS model (Summarize, Narrow, Analyze, Probe the preceptor, Plan management, Select an issue for self-directed learning) (Wolpaw, Wolpaw, & Papp, 2003).
  • Analyze student anxiety levels and perceptions of the exercise.
  • Identify barriers and facilitators to learning.

Theoretical Framework

The simulation model by Jeffries (2005) was used as a framework for implementation of the Pediatric Examination Practice (PEP) Days teaching intervention. The Jeffries simulation model includes five components: teacher, student, educational practice, simulation design, and outcomes. The first component sets high expectations for students in terms of how to approach a child and pediatric visit. Many students enter the PNP program through an accelerated curriculum, allowing advancement from the baccalaureate to graduate program without a period of nursing work experience. As a result, many students lack an organizational structure when conducting a health assessment. The PEP days intervention was structured using the American Academy of Pediatric Bright Futures resources to provide students with a framework to organize their patient encounter, facilitate case presentation in a organized manner, and reduce anxiety associated with obtaining a history and performing a pediatric examination. Teaching outcomes included having students demonstrate core knowledge of pediatric developmental milestones and age-appropriate anticipatory guidance, conduct a thorough history and physical examination, and efficiently report clinical findings to their faculty preceptor using the SNAPPS format.

Method

The teaching intervention was conducted in four 3-hour sessions with 10 to 12 children, accompanied by a parent or guardian. Each session was attended by 12 to 17 nurse practitioner students, and they were held weekly over 4 weeks. Of the participants, 14 were PNP students, three were neonatal nurse practitioner (NNP) students, and 14 were emergency/family nurse practitioner (ENP) students. Using a variety of Web recruitment strategies, 40 children aged 4 months to 14 years were recruited to participate. As this intervention was piloted the year before, an e-mail was generated to previous participants with a link to a Google form to signify which dates were available. The same e-mail was also circulated throughout the nursing school for recruitment of young children from students, staff, and faculty. Everyone was encouraged to share the e-mail and an incentive of $40 per child was provided for participation for each session. Because the patients were not actors, as in usual standardized patient scenarios, the children and parents or guardians were instructed to consider each student clinical encounter as a typical well child health maintenance office visit. Although no scripts were used, participants were asked to be consistent with their histories and clinical concerns from student to student. Parents and guardians were invited to share only what they felt comfortable sharing during the visit.

Student clinical visits took place in a laboratory space that had been a former outpatient clinic consisting of 12 examination rooms outfitted and stocked with equipment required for conducting a basic physical examination. Screening stations were also offered for obtaining vital signs, eye screenings, and heights and weights, as well as small conference spaces for reporting clinical findings to faculty.

Prior to the first session, the students were modeled a complete physical examination for a well child by faculty in the laboratory setting. During their first session with the pediatric patients and their family member, students worked in dyads to obtain vitals signs and to conduct developmental screens, while also completing an intake form for each patient. Student dyads then gathered the history and conducted the physical examination of the child. The intake form was left within the child's chart for subsequent students to use. Subsequent students would evaluate vital signs and developmental screens to include in their report, but would focus on gathering the history, conducting the examination, and educating the parent and child on anticipatory guidance.

Following the clinical encounter, students would then come to the nurse's station or small conference space to present their findings to a faculty preceptor using the SNAPPS format. The SNAPPS format consists of summarizing the case, narrowing differential diagnoses, analyzing the assessment, probing the preceptor, planning patient management, and selecting an issue for self-study (Wolpaw et al., 2003). After completing the first case as a team, students subsequently conducted examinations and presented findings individually. Senior PNP students, in their final semester, were also present and functioned as preceptors to answer questions, demonstrate techniques, and provide student feedback. During the final two of the four sessions, PNP students, now familiar with the simulation, served as role models for each ENP student, demonstrating how to conduct the pediatric clinical encounter. ENP and PNP students worked as a team for the ENP student's first pediatric examination, and then performed the examinations and presented findings to their faculty independently. Faculty were available to evaluate student case presentations and, in some cases, were available to observe the individual clinical encounters allowing for constructive evaluation while the encounter was in progress.

Students were generally able to complete three to five well child examinations during each simulation session. PNP students were required to attend three sessions, the NNP students attended two sessions, and the ENP students each attended one session. PNP and ENP students completed an online survey, using Google forms, after each session. Survey questions included a 5-point Likert scale to assess anxiety before and after the session, with 5 = most anxious and 1 = least anxious. Surveys also assessed student expectations about the experience, opinions about barriers and facilitators during the session, and suggestions for how to improve the simulation, including an open-ended comment section. Faculty used student survey comments each week to improve and modify subsequent sessions when appropriate.

Results

For the first session, the 14 PNP students reported an initial mean anxiety score of 3.85, ranging from 3 to 5, with comments expressing concern about not knowing exactly what to expect from the experience. Qualitative comments revealed student confidence increased during the simulation. One student stated:

During the session, I felt way more comfortable. I enjoyed the relaxed, comforting environment. I felt like it was a great learning experience. What worked for me was reporting off to [the faculty] and hearing their feedback. To help make the suggestions stick, once I got feedback, I asked if I could repeat certain parts of the reporting back to help make the suggestions stick. Additionally, I really liked how I was even able to follow others and observe, because that also helps me learn, in addition to doing the patient assessments myself.

Another student stated:

It helped me to go in with a partner first to break the ice, and then I felt more comfortable going in alone. The only barrier I can think of is how long it took sometimes to report off. However, the feedback I received during report was extremely helpful. As a nurse already, I am pretty comfortable with my assessment skills, but talking to faculty and [fourth-semester] students is where I feel like I learn the most.

Per faculty feedback, student case presentations improved within sessions and over time. Faculty also noted that students appeared more confident with their assessments and presentations, with reports becoming more focused and organized, yet comprehensive. During the second and third sessions, the PNP student mean anxiety scores decreased from the initial 3.85 to 2.77 and 2.67, respectively. ENP students, most of whom had previous nursing experience, had lower initial mean anxiety scores (2.8) ranging from 1 to 5, compared with PNP students.

Students feedback about the sessions provided helpful suggestions to improve the experience and in identifying barriers. During the second session, one student commented:

I really appreciate having so many faculty to hear us report, remind us what we have missed, and provide pearls to help make us better with assessment!

During the final session, another student commented:

I was nervous to be watched by another student, but once we started, I felt confident and enjoyed being able to work with someone else. It was neat to realize how far we've come since our first PEP session!

ENP students offered these comments about the learning experience. One student stated:

I thought it was a very valuable learning experience. I have had no experience with well child [examinations] and have not done a head-to-toe assessment on a child before. It was great to be paired with a PNP first, as I have never seen a head-to-toe assessment for a child and [I]don't know what adaptations from the adult [examination] that need to be made. It was a little challenging knowing what [examinations] to do and not to do across the age ranges for the physical [examination] portion.

Another student commented:

I think just talking with professors about patients is extremely helpful, and we should have more of it. Interacting with knowledgeable teachers is very valuable, and I wish we had more opportunities like that.

Discussion

The teaching innovation using well children accompanied by their family members within a faculty-proctored session proved an invaluable experience in preparing APRN students for community clinical experiences. The sequential progressive dosing of these clinical exposures provided excellent opportunities for students to perfect their skills while also building confidence and reducing anxiety. The simulated environment allowed students to experience a clinical environment similar to their clinical placement, which is consistent with the findings by Schram and Mudd (2015), who explored building APRN clinical competencies through the use of standardized patients, which allowed for a engaged learning environment. The SNAPPS case presentation format that was used to guide student case presentation was also found to be useful in teaching students how to concisely report their findings (Seki et al., 2016). The PEP simulation sessions provided PNP students with 16 hours of clinical experience time performing well child assessments of 15 to 20 children, ranging from infancy to adolescence, and readying them for their first actual community pediatric clinical rotations within a safe environment with supportive faculty and student colleagues.

Anxiety among nurses in training is common and may create barriers to learning that interfere with clinical performance and foster poor coping skills (Hughes, 2005). In addition, mounting anxiety in the learning environment may interfere with concentration, memory, and the ability to solve problems (Beddoe & Murphy, 2004). The results from the current teaching intervention suggests that increasing exposure using a faculty-proctored clinical experience with actual children and their families helps to reduce student anxiety, as evidenced over time. The current findings are in accordance with a systematic review that examined the effect of anxiety among nursing students using stimulation experiences (Shearer, 2016). Similar to the common themes drawn by Shearer (2016), prior to the simulation sessions, students expressed personal anxiety derived from the unknown, fear of critique by faculty and other students, and fear of making mistakes. This project was designed to provide students with an experience as close as possible to an actual pediatric clinical encounter. Although the authors are hopeful that these initial results show improved clinical experiences in the field, limitations of this project, including a small sample size, self-reported assessment of student anxiety, no standardized measure of student clinical performance, and a lack of capturing student progress with SNAPPS skills over time prevent the authors from making any claims that are generalizable.

Without measuring student anxiety using a valid and reliable instrument, individual changes in anxiety among participants was not able to be reliably compared. Finally, collecting data from community preceptors to measure improved student performance would have supported the level of success for the project. However, faculty and students all reported that the simulation sessions were valuable, justifying their continued use in the future where the authors plan to continue the practice of demonstrating one clinical visit, practicing skills, and then having students teach their peers to ensure clinical competency across APRN clinical specialties.

Summary

The teaching intervention, known as PEP days, offers promise that students will become better prepared to function in the APRN role as they enter clinical settings. Using progressive exposure to real people in a real-life clinical setting, this model may augment training in situations where preclinical preparation is difficult or limited.

References

  • Beddoe, A.E. & Murphy, S.O. (2004). Does mindfulness decrease stress and foster empathy among nursing students?Journal of Nursing Education, 43, 305–312.
  • Hughes, B. (2005). Study, examinations and stress: Blood pressure assessments in college students. Educational Review, 57, 21–36. doi:10.1080/0013191042000274169 [CrossRef]
  • Jeffries, P.R. (2005). A framework for designing, implementing, and evaluating: Simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26, 96–103.
  • Larue, C., Pepin, J. & Allard, É. (2015). Simulation in preparation or substitution for clinical placement: A systematic review of the literature. Journal of Nursing Education and Practice, 5, 132–140. doi:10.5430/jnep.v5n9p132 [CrossRef]
  • Schram, A.P. & Mudd, S. (2015). Implementing standardized patients within simulation in a nurse practitioner program. Clinical Simulation in Nursing, 11, 208–213. doi:10.1016/j.ecns.2015.02.002 [CrossRef]
  • Seki, M., Otaki, J., Breugelmans, R., Komoda, T., Nagata-Kobayashi, S., Akaishi, Y. & Isumi, M. (2016). How do case presentation teaching methods affect learning outcomes?-SNAPPS and the One-Minute preceptor. BMC Medical Education, 16, 1–7. doi:10.1186/s12909-016-0531-6 [CrossRef]
  • Shearer, J.N. (2016). Anxiety, nursing students, and simulation: State of the science. Journal of Nursing Education, 55, 551–554. doi:10.3928/01484834-20160914-02 [CrossRef]
  • Wolpaw, T.M., Wolpaw, D.R. & Papp, K.K. (2003). SNAPPS: A learner-centered model for outpatient education. Academic Medicine, 78, 893–898. doi:10.1097/00001888-200309000-00010 [CrossRef]
Authors

Dr. Reyes is Pediatric MSN Specialty Coordinator and Clinical Assistant Professor, Dr. Close is Assistant Research Professor, Dr. Rodriguez is Assistant Professor, and Dr. Evans is Family/Emergency MSN Specialty Coordinator and Clinical Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.

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

This pilot project was funded by a $3000 Fund for Innovative Teaching (FIT) grant from Emory University to support the cost of the real-life standardized patients in the form of gift cards. The authors thank the children and families who participated in this project.

Address correspondence to Imelda Reyes, DNP, MPH, RN, APRN-BC, Pediatric MSN Specialty Coordinator and Clinical Assistant Professor, Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road, Suite 432, Atlanta, GA 30322; e-mail: ireyes@emory.edu.

Received: March 03, 2017
Accepted: April 06, 2017

10.3928/01484834-20170817-07

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