Creating Clinical/Simulated Learning Experiences

Teaching in the Clinical Setting*

Paula Gubrud, EdD, RN, FAAN

The health care system is ever changing and the Patient Protection and Affordable Care Act (PPACA) (Patient Protection and Affordable Care Act, 2014) challenges faculty to prepare students for future roles and to practice in a health care system that is patient-centered, wellness-oriented, community- and population-based, and technologically advanced. Clinical settings within a variety of health care systems have also become highly complex. Clinical learning occurs in actual health care environments and laboratory settings where students apply their acquired knowledge and skills as they think critically, make clinical decisions, and acquire professional values necessary to work in the practice environment. The purpose of this chapter is to describe the environments for clinical teaching and learning, how the curriculum relates to clinical teaching, roles and responsibilities of clinical teachers, and teaching methods and models that facilitate learning in clinical environments.

Practice Learning Environments
The environment for practicum experiences may be any place where students interact with patients and families for purposes such as acquiring needed cognitive skills that facilitate clinical reasoning and decision-making as well as psychomotor and affective skills. The practicum environment, also referred to as the clinical learning environment (CLE), is an interactive network of forces within the clinical setting that influence students’ clinical learning outcomes. The environment also provides opportunities for students to integrate theoretical nursing knowledge into nursing care, cultivate clinical reasoning and judgment skills, and develop a professional identity (O’Mara, McDonald, Gillespie, Brown, & Miles, 2014). The CLE introduces students to the expectations of the practice environment, as well as the roles and responsibilities of health care professionals. To accomplish these outcomes, a variety of experiences are required in multiple settings. These settings may be special venues within schools of nursing or within acute care settings or communities. It is essential that practice environments be supportive and conducive to learning so that students will develop the qualities and skill abilities needed to become competent professionals (O’Mara et al., 2014). The following section describes these settings. Included among these are practice learning centers such as learning labs, acute and transitional care, and community-based environments.

Clinical Learning Resource Centers
To foster a nonthreatening and safe learning environment, the practice learning center is used at several stages of students’ learning. These centers encourage guided experiences that allow students to practice and perfect a variety of psychomotor, affective, and cognitive skills such as critical thinking and clinical reasoning before moving into complex patient environments. Simulation is one example of a teaching method used in the practice learning center. This method is increasingly used to evaluate knowledge acquisition as well as skill sets (Jeffries, 2014).

Simulation
According to the National Council of State Boards of (NCSBN, 2005), “simulation is a teaching strategy used to validate the complex and comprehensive skill required of health care professionals.” 283Simulation-based learning is designed to replicate the reality of the clinical environment to provide participants with opportunities to practice and refine clinical reasoning, skilled procedures, and interprofessional collaboration. Schiavenato (2009) also states, “The human patient simulator (HPS) or high-fidelity mannequin has become synonymous with the word simulation in nursing education” (p. 388). The explosion of simulation as a standard clinical learning activity is evident in the literature and a recent multisite study validates the use of this modality in clinical education (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). This study included 10 prelicensure sites and used a three-group quasiexperimental research design. The control group had traditional clinical experiences with no more than 10% of their time spent in simulation. One experimental group had 25% of their clinical time in simulation, and the other experimental group spent 50% of their clinical time in simulation. The study began with the first clinical courses and used multiple measures to assess participants’ nursing knowledge and clinical competency throughout the entire program of study. Study participants also rated how their learning needs were met in both simulation and in the clinical environment. Study results found no significant differences between all groups among assessment measures. The study validates simulation as high-quality clinical learning experience that can be used to replace a significant number of traditional clinical hours.

Virtual Clinical Practica
Given the challenges of finding sufficient clinical experiences for students, faculty are exploring the use of virtual clinical experiences made possible by online technologies that can create virtual clinical environments (Knapfel, Moore, & Skiba, 2014) and use existing technologies such as electronic intensive care units and telehealth capabilities to create opportunities for clinical experiences focused on providing opportunities to practice critical thinking, clinical reasoning, communication, and teamwork as a member of the interprofessional team (Sepples, Goran, & Zimmer-Rankin, 2013). The virtual clinical practicum (VCP) is designed to provide a live clinical experience to nursing students from a distance. Students gain clinical experience and practice skills and clinical judgment using telehealth technologies in which students observe a nurse taking care of a patient in a clinical setting without going to the actual clinical site, or as a registered nurse in masters doctoral programs who are learning to provide the care. The students can interact with the nurse, other members of the interprofessional team, and the patient using telehealth technology. The VCP process is developing as a potential solution in response to limited clinical practice sites as well as limited clinical experts, and for specific populations such as acute care pediatric patients. VCP provides needed clinical learning opportunity, especially in rural areas. (See Chapter 21 for further discussion of virtual environments.)

Acute and Transitional Care Environments
Acute and transitional care environments provide clinical experiences for undergraduate and graduate students preparing for advanced practice roles. Experiences in these environments enable undergraduate students, in particular, to exemplify caring abilities and practice the use of cognitive, psychomotor, and communication skills as they interact with patients and their families. These environments have become increasingly complex. A recent multisite study found that the complexity relates to factors such as extensive use of technology (e.g., electronic health records), rapid patient and staff turnover, high patient acuity, and complex patient needs (McNelis et al., 2014). These sites are suitable for learning experiences that focus on providing care in complex clinical settings, but faculty must consider the level of the student, the focus of the experience and the increased risk to patient safety when students have clinical assignments in these units.

Clinical Cases, Unfolding Case Studies, Scenarios, and Simulations
Simulated experiences that provide opportunities for students to integrate psychomotor, critical thinking, and clinical reasoning decision-making skills are equally valuable in assisting students to critically evaluate their own actions and reflect on their own abilities to apply theory to practice. The use of the high-fidelity HPS is one example of using realistic scenarios to prepare students for clinical experiences, substitute for unavailable or unpredictable clinical experiences, or enhance clinical experiences in a safe environment. The use of HPS helps transition the student from the classroom to the practicum environment. Students’ learning with the HPS method can be enhanced, patient care can 284be optimized, and patient safety can be improved. Additional benefits may include enhanced learning in a risk-free environment, promotion of interactive learning, repeated practice of skills, and immediate faculty or tutor feedback. (See Chapter 18 for additional discussion.) Cases, unfolding case studies, and scenarios are lower fidelity strategies but are equally helpful in preparing students for clinical experiences and bridging the gap between classroom and practice (Benner, Sutphen, Leonard, & Day, 2010; McNelis et al., 2014).

Community-Based Environments
The health care delivery system and implementation of the PPACA is continuing to shift nursing practice from acute care hospital environments to the outpatient and community settings. These changes have resulted in care provided through the medical home model (Henderson, Princell, & Martin, 2012) and an increased use of community agencies such as ambulatory, long-term, home health, and nurse-managed clinics; hospice; homeless shelters; social agencies (e.g., homes for battered women); physicians’ offices; health maintenance organizations; and worksite venues and summer camps.
The use of technology such as video conferencing, wireless remote communication, information systems, and online courses has made it possible for clinical experiences in a community-based environment to occur at a distance. The transition to community-based teaching requires the faculty to ensure that learning opportunities available in the clinical placement allow the student to achieve the learning objectives. Faculty must adapt clinical learning experiences and incorporate skills used to develop competency with new technology and modify teaching methods (Bisholt, Ohlsson, Kullén Engström, Sundler Johansson, & Gustafsson, 2014). Additionally faculty must adapt to methods of clinical supervision such as being accessible by mobile phone and texting.
Establishing appropriate and sufficient learning experiences in the community may be difficult and challenging. These challenges often relate to economic constraints and the changes in nurse staffing patterns, with a resultant lack of time for professionals to facilitate skill development and serve as role models. These challenges may require faculty to be creative in their use and selection of resources within these environments and to consider establishing partnerships with the service agencies. Using community-based settings creates opportunity for critical thinking, understanding the health care system, and development of communication skills. Faculty can provide other experiences using simulation or the clinical learning laboratory to assist students to develop proficiency in skills traditionally performed in the acute care setting.

Learner-Centered Clinical Education Environment
Every health care environment and specific unit within these environments has a culture. The culture of the immediate environment affects teaching and learning (O’Mara et al., 2014). For example, the culture or patterns of actions and behaviors of the health care professionals can be observed in their attitudes, interactions, teamwork, and commitment to quality and safe patient care. Staffing levels, acuity of patients, anxiety of staff, and workload can influence these actions and behaviors. These aspects of the culture of the environment can in turn influence the time staff has to devote to students. The culture of the environment may also result in behaviors related to lateral violence. Lateral violence is often observed, witnessed, and verbalized by students. These verbalizations provide an opportunity for faculty to implement strategies and assist students with processing what they may be seeing, hearing, and feeling, and thus lessen the effects of these behaviors on students’ learning. For example, faculty can hold debriefing sessions, listen to students’ perceptions, and make concerted efforts to balance students’ feelings and thoughts by using appropriate strategies to soften, yet not deny, the reality of the culture.

Selecting Health Care Environments
Regardless of the practice environment, faculty are responsible for selecting appropriate CLEs within health care agencies and other organizations such as schools and social service agencies. Faculty must be aware of what particular systems are in place within the program to negotiate contracts that are congruent with the philosophies of the school of nursing and the agency, as well as those that specify the rights and responsibilities of both. Determinations must be made about regulation and accreditation status, adequacy of staff, the patient population for needed experiences, expected course outcomes, and whether or not the practice model is compatible for intended uses and curriculum needs. In addition, the 285adequacy and availability of physical resources (e.g., conference space) for students and faculty should be determined. Finding a practice environment that meets all specified needs is becoming a challenge because of factors associated with the delivery of health care. For example, rapid patient turnover often means faculty have to select available patients rather than those that best meet students’ learning needs. This limitation in patient availability can create opportunities for faculty to be creative in the manner in which learning experiences are selected and teaching strategies used. Regardless of the limitation, the role of the faculty is to assist students in making learning connections focused on application of content presented in the classroom to clinical practice. Dual clinical and classroom assignments for faculty may assist in making those necessary connections between clinical and classroom. “The very strength of pedagogical approaches in the clinical setting is itself a persuasive argument for intentional integration of knowledge, clinical reasoning, and skilled know-how and ethical comportment across the nursing curriculum” (Benner et al., 2010, p. 159). Thus faculty have a significant role in helping students to make the necessary connections between clinical and classroom experiences as they learn to think and act like a nurse (Tanner, 2002), in spite of limitations for clinical learning in the health care environment.

Building Relationships with Personnel within Health Care Agency Environments
The ability of the clinical faculty to facilitate students’ learning can be enhanced when an effective working relationship is established within the clinical agency. Effective relationships begin with effective communication, which must be practiced in an ongoing manner to maintain relationships and facilitate learning (Dahlke, Baumbusch, Affleck, & Kwon, 2012). This requires having an understanding of the environment and the roles of the individuals within the environment, adapting teaching approaches to the situation, and establishing relationships aimed toward enhancing the educational experience. These elements do not exist in isolation but are patterned to dovetail with or complement other roles. Information should be shared continually, clearly, and consistently about goals, competencies, and expected outcomes; the level of students; practice expectations; the clinical schedule; and related information. Such information enables staff to assist with identification of appropriate experiences for students.
Inasmuch as clinical faculty have the primary responsibility for teaching and guiding students in the clinical environment, others often assist in the process. Therefore the sharing of expectations with the staff is critical. Ensuring an orientation to the practicum environment and having students engage with staff early in the clinical experience promote positive student–staff interaction and provide opportunities for role clarification and the development of collegial relationships. A consistent demonstration of awareness of the mission and values of the agency through actions that are inherently respectful is crucial. Follow-up communication provides an avenue for those within the practice environment to keep abreast of changes.

Clinical Practicum Experiences across the Curriculum
Understanding the Curriculum
The curriculum, composed of a series of well-organized and logical entities, guides the selection of learning experiences and clinical assignments, organizes teaching–learning activities, and informs the measurement of student performance. The manner in which the curriculum is organized guides the planning of learning experiences in a logical, rational sequence. The curriculum is designed to build on prior knowledge and to reinforce the application of learning. While this description of curriculum relates to process, this does not preclude faculty’s use of creative and innovative methods in clinical environments. Creative methods have a high potential to motivate students and facilitate construction of knowledge to be applied in practice. Studies focused on perceptions of both clinical instructors and students indicate understanding the whole curriculum is a critical aspect of clinical instruction (Bisholt et al., 2014; Dahlke et al., 2012; Wyte-Lake, Tran, Bowman, Needlemann, & Dobablian, 2013). As students progress and engage in varied practicum experiences, it is faculty’s responsibility to interpret the curriculum and to describe the relationships between course competencies and practicum experiences.

Understanding the Student
Clinical experiences provide opportunities for students to practice the art and science of nursing, which enhances their ability to learn. To maximize these 286experiences, faculty must have full knowledge and understanding of each student (see also Chapter 2). The nursing student population is culturally diverse and includes members of varied age groups, many ethnic and racial groups, and an increasing number of men. This population is also likely to include persons with (or without) prior degrees from a variety of disciplines, as well as those who possess many different health care experiences and technological skill levels. In addition, students differ in their learning styles, levels of knowledge, and preferences for learning experiences; therefore faculty must make concerted efforts to balance the students’ learning needs, interests, and abilities when selecting clinical experiences without losing sight of the curriculum and expected competencies and outcomes. Such action can be facilitated by making an assessment of the knowledge, culture, and skills of the learner. Such an assessment helps the faculty determine whether students possess the cognitive, critical thinking, clinical reasoning, decision-making, psychomotor, and affective skills needed for the experiences.

Understanding the Clinical Environment
The clinical environment has been described as a place where students synthesize the knowledge gained in the classroom and make applications to practical situations. Chan (2002) describes the CLE as “the interaction network of forces within the clinical setting that influences student learning outcomes” (p. 70). A number of forces affect expected learning outcomes, including the availability of staff for supervision and coaching, and the degree of student-centeredness exhibited by the clinical teachers (Chan, 2002; Newton, Jolly, Ockerby, & Cross, 2012). Additionally, opportunities available for students to pursue individual learning outcomes define the effectiveness of the clinical environment (Newton et al., 2012). The extent to which the clinical environment values nurses’ work and provides an adaptive culture that embraces innovation, creativity, and flexible work practices also are important aspects that set the stage of effective learning (Newton et al., 2012). These forces, coupled with the need to adjust to an environment that requires an integration of thinking skills and performance skills, often result in increased anxiety among students. Creating a supportive clinical environment involves comprehensive orientation of students to the environment, ensuring they are prepared to perform necessary skills and encouraging creative and critical thinking (Ganley & Linnard-Palmer, 2010). Creating an environment where students are expected to succeed also reduces student anxiety (Ganley & Linnard-Palmer, 2010).
Traditionally, clinical rotations have consisted of short blocks of time spent on a unit caring for a patient or two, mostly performing nursing skills with little or no time dedicated to focus on integration of theory, application of critical thinking, and clinical reasoning. Often there is minimal focus on providing feedback or effective evaluation of the interventions performed. Additionally, the focus of the CLE is often focused on the operational aspects of the unit. staff are expected to meet productivity goals and are caring for patients that are extremely ill with multiple health care needs in complex and dynamic organizations. Nurses intuitively want to be good role models and nurture students but often do not have the time to do so. Faculty must balance the operational needs of the unit with the importance of ensuring that students receive feedback and have the opportunity to focus on daily learning goals related to clinical course outcomes.
Regardless of location of the practice setting, faculty and staff should provide an environment in which caring relationships are evident. The clinical practice environment should be a place where students feel that they are accepted and their contributions are appreciated by individuals with whom they interact (Chan, 2002). Attributes of staff such as warmth, support in obtaining access to learning experiences, and willingness to engage in a teaching relationship are considered helpful.

Selecting Clinical Practicum Experiences
Practicum experiences refer to all activities in which students engage in the practice of nursing. Such experiences are essential for knowledge application, skill development, and professional socialization. Practicum experiences are selected and planned to provide students with opportunities to work across settings and manage care for varied populations with emphasis on applying theory content from the classroom to the clinical experiences. Clinical experiences should include an emphasis on the nursing roles related to health promotion and disease prevention. Selection of practicum learning experiences requires all faculty to be knowledgeable about clinical education and have a sound understanding of the curriculum, the learners, and the learning environment.
287
The practicum experiences should also help students prepare for outcomes in a progressive, developmental manner. Experiences with patients from diverse populations and with different levels of wellness should be provided. Faculty should take advantage of opportunities to use their creative talents, clinical skills, and expertise to ensure that all students have opportunities to interface virtually or directly with a variety of patient populations.
As faculty begin to plan the clinical experience, it is essential to determine the goal of the particular clinical experience for that day. For the beginning student, focused clinical experiences in which the student is to focus on specific objectives and to achieve specific competencies incorporating individual learning needs requires faculty to create focused, goal-oriented learning activities (Gubrud-Howe & Schoessler, 2009). In a focused clinical learning activity, instead of providing all required care for one or two patients, students can focus on becoming proficient at a particular skill by practicing that skill for several patients. For example, students may interview several patients to work on communication skills, perform vital sign assessments on multiple patients to develop this particular skill set, or focus on learning standards of care in a specialty area. Organizing learning experiences allowing students to assign and delegate care or give and receive reports are other examples of focused clinical learning activities. The purpose of focused clinical learning is to design clinical learning experiences focusing on repetitive practice related to a particular skill set. Focused experienced should integrate students’ individual learning needs and focus on course outcomes.
Other learning goals may emphasize facilitating students’ ability to synthesize information, integrate didactic and clinical knowledge, develop clinical reasoning and judgment skills, and plan care for groups of patients (Benner et al., 2010; Tanner, 2010). Here, assignments that involve planning care for patients with complex needs and for multiple patients are appropriate. These integrative clinical experiences prepare students for transition to practice and typically occur toward the end of the program.
The selection of experiences should be consistent with the desired course and curriculum outcomes, which may be multiple and specific to the nursing program. For example, the expected outcomes for students in an undergraduate degree nursing program are different than those for students in a graduate degree program. Therefore the learning experiences and clinical environment that are selected and the practice opportunities that are offered to students should be congruent with the program outcomes.

Interprofessional Clinical Education
Learning to collaborate with the many health care groups involved in patient care can be a daunting task. Through these experiences, nursing students can learn to work collaboratively with a variety of health disciplines. Therefore students should be provided with opportunities to work as members of interprofessional teams and in practice environments where practice models are used for joint planning, implementation, and evaluation of outcomes of care. The goal of interprofessional education is to foster development of teamwork competencies while enhancing contribution to each profession.
Interprofessional simulations may assist students in health care disciplines such as nursing, medicine, pharmacy, and respiratory therapy to learn about the clinical management of a variety of patients. Several recent studies demonstrate interprofessional simulations may improve patient care through shared learning, development of collaborative team functioning, and shared knowledge creation leading to trust and thoughtful decision making (Bandali, Craig, & Ziv, 2012; Reese, Jeffries, & Engum, 2010; Smithburger, Kane-Gill, Kloet, Lohr, & Seybert, 2013; Strouse, 2010).
faculty are increasingly participating in teams and designing interprofessional clinical courses and learning experiences. Successful course development and implementation depend on faculty’s commitment to the goal of interprofessional practice and a wide range of additional factors. For example, educators must demonstrate professional respect and role clarity. Educators must also have the ability to secure clinical facilities and develop schedules for clinical experiences that are compatible with the concurrent coursework and curriculum progression in each discipline. Other factors include identification of content and experiences with similarities, differences, and overlaps, as well as clarification of autonomy and role interdependency. Success depends on the ability to identify philosophical similarities and differences in clinical practice and to establish clear communication through avenues such as frequent interdisciplinary clinical conferences.
288
An expected outcome of interprofessional education is increased future collaboration among professionals (Interprofessional Education Collaborative Expert Panel, 2011). The assumption is that students who are taught together will learn to collaborate more effectively when they later assume professional roles in an integrated health care system. Rewards and benefits of interprofessional practice and education include clearer understanding of roles and better employment opportunities for graduates. The long-term outcome is improved access to care, quality care, and increased patient satisfaction and safety. (See also Chapter 11.)

Evaluating Experiences
Students are required to demonstrate multiple behaviors in cognitive, psychomotor, and affective domains. Consequently, clinical faculty must evaluate students in each of these areas. The evaluation must be both ongoing (formative evaluation) to assist students in learning and terminal (summative evaluation) to determine learning outcomes. Constructive and timely feedback, which promotes achievement and growth, is an essential element of evaluation. For a discussion of clinical performance evaluation, refer to Chapter 25.

Scheduling Clinical Practicum Assignments
Although faculty schedule clinical practicum experiences to promote learning, there is ongoing dialogue about the best way to schedule experiences, with emphasis placed on the length of the experiences (hours per day, number of days per week, number of weeks per semester), the timing of the experiences in relation to didactic course assignments, and student needs. Faculty should consider course goals related to both theory and clinical courses and integration of theory content with clinical experiences when making scheduling decisions.
When the learning goal is to integrate students into a …