Camille N. Scronce Nursing Education E-Portfolio



Clinical Conferences in Nursing EducationCamille N. ScronceDuke University School of NursingJune 30, 2013IntroductionNursing educators have the difficult task of preparing nursing students to be able to effectively care for diverse and complex patients in a fragmented and ever-changing healthcare system. Specifically, clinical educators are tasked with helping nursing students integrate theory into practice. This means ensuring “students are able to correlate classroom content with the practical realities of the clinical setting” (O’Connor, 2006, p.19). The gap between theory and practice in nursing education is well documented in the literature. Benner and colleagues (as cited in Tanner, 2000) noted new nurses transitioning to practice are not prepared with the knowledge and skills necessary to provide care for today’s patients nor are they prepared to provide care for future healthcare needs. Limited integration between classroom and clinical experiences has been cited as one of the major causes of this problem (Tanner, 2000). A study of new nurse graduates’ perceptions of their educational preparation found many new nurses felt unprepared for clinical practice and leadership and management roles (Candela & Bowles, 2008), further stressing the importance of the integration of theory into clinical experiences.Clinical conferences have been utilized in the clinical setting as a teaching strategy to engage students; enhance and reinforce learning; develop critical thinking and problem-solving; improve clinical reasoning and judgment; and ultimately facilitate integrating theory into practice (Hsu, 2007). This topic was selected because the ability of nurses to deliver quality, safe and effective nursing care begins with nursing education. In my future role as a clinical instructor, I want to be able to properly utilize clinical conferences as a way to help bridge the gap between student’s acquired knowledge and the skills needed to provide effective patient-centered care. Thus, the purpose of this paper is to discuss the historical context of clinical conferences; explore strategies utilized by clinical instructors during clinical conferences; analyze the current literature on good practices for clinical conferences; and recommend ways instructors can plan and implement effective clinical conferences. The Historical Context of Clinical Conferences in NursingClinical conferences are a major part of the clinical experience in nursing education. The literature on clinical conferences dates back to the late 1960s with Lister (as cited in Letizia, 1998) recommending clinical conferences as a way to enhance student’s clinical learning and provide the opportunity for students to synthesize their learning. Matheney (1969) described pre-conference as a discussion and planning session held immediately before the clinical learning experience with the purposes of providing guidance for the clinical day; setting the groundwork for the experience; recognizing the scope and limitations of the nurse’s role; and reinforcing problem-solving, the application of knowledge and the use of judgment. Matheney (1969) described post-clinical conference as the group discussion immediately after the clinical learning experience with the purposes of analyzing the clinical experience; clarifying the relationship between theory and practice; developing guidelines and details in providing nursing care; clarifying thinking (cognitive) and feeling (affective); keeping the focus on patients as people; and reinforcing problem-solving, the application of knowledge and the use of judgment. The concepts of experiential learning, reflection and debriefing lay the foundation for clinical conferences. As a practice discipline, clinical learning is a major focus of nursing education. However, Freire and Mezirow (Fowler, 2008) emphasized that the fundamental part of learning is the way we process our experiences. Experiential learning is learning by doing. It allows students to acquire and apply knowledge, skills and feelings in an immediate and relevant setting (Fowler, 2008). According to Desjarlais and Smith (2011), "reflection is a process that involves playing back a period of time related to previous valued experiences in search of significant discoveries or insights about oneself, one’s behaviors, one’s values, or knowledge gained” (p.3). Debriefing allows students to explore and make sense of their experiences. Students explore what happened during the experience discussing what went well and identifying what could be done to change or improve the experience the next time (Gardner, 2013). All of these concepts are instrumental components of clinical conferences.Today, clinical conferences may be conducted at the beginning of the clinical experience (pre-clinical conference); during the middle of the clinical experience (intra or mid-clinical conference); or at the end of the clinical experience (post-clinical conference). Although clinical conferences have been a part of nursing education for over 40 years, there is no consistency in when and how they are implemented and conducted in nursing education.What Clinical Instructors Are Doing During Clinical ConferencesIn exploring current strategies clinical instructors utilize during clinical conferences, six instructors were interviewed and one video of a post-clinical conference was viewed. Leigh Mullen, MSN, RN is a clinical instructor at the University of North Carolina at Chapel Hill School of Nursing. Ms. Mullen teaches first semester nursing students as a part of the course Nursing Care of Adults with Major Health Problems I (Medical-Surgical Nursing I). The course requires students to complete a total of 120 hours of clinical time in a facility. Ms. Mullen is with her students two days per week for a total of 13 to 14 hours among the two days. Ms. Mullen reported her clinical group has eight clinical conferences and only two of the clinical conference topics are predetermined by the course syllabus. The clinical conference is held at the end of the second day (at the end of the clinical week). Ms. Mullen dedicates the first thirty minutes of the clinical conference to discussing a topic related to clinical practice. For example, one clinical conference was on the topic of common post-operative complications. For another clinical conference, the Director of the facility’s Infection Control Department spoke with her students. The last thirty minutes of the clinical post-conference allows students to debrief and talk about their patient care and learning experiences from the two clinical days. When asked if there was anything she would change about her clinical conferences, Ms. Mullen noted clinical conferences often start late due to students trying to finish their care on the floor and this causes students to leave late. She reported she is trying to better organize the clinical day so her students do not feel rushed and are relaxed going into the clinical post-conference (L. Mullen, personal communication, June 18, 2013).Ryan Lewis, MSN, RN is a clinical instructor at Pitt Community College School of Nursing. He teaches first and second level didactic courses and has a senior student clinical group. The senior clinical group is for the course Complex Health Concepts. This course requires a total of 20 clinical hours per week. Mr. Lewis noted clinical conference topics are not predetermined and that instructors have academic freedom to teach within the course guidelines. He also noted students may have pre-assigned research assignments or may be asked to prepare something specific for their clinical experience as it relates to their didactic content. Mr. Lewis conducts pre and post-clinical conferences. During the pre-clinical conference, he assigns students with their nurses and patients, gives a brief overview of the day and answers any questions regarding the clinical experience. Mr. Lewis noted pre-clinical conferences are brief, but post-clinical conferences are generally an hour. During the post-clinical conference, Mr. Lewis began by recapping any important issues for the day and reminds students of things he observed that need to be corrected or adjusted for the next clinical experience. As a part of the post-clinical conference students may perform chart reviews, discuss patient experiences, complete a team teaching assignment or participate in role play activities. For example, Mr. Lewis may take a situation from the clinical day such as poor communication and have his students teach each other through role play. Mr. Lewis noted that he is known to have a huddle in the middle of the clinical experience when his clinical team has experienced something new like a code blue or when he sees students being unproductive (R. Lewis, personal communication, June 13, 2013).Leslie Johnson, MSN, RN is a clinical instructor at Wake Technical Community College and teaches students in the Introduction to Health Concepts course. This course requires six hours of clinical experience per week. Ms. Johnson reported she has post-clinical conference with her students at the end of the clinical day. She noted students perform a range of activities in the post-clinical conference from learning about new equipment, visits from special guests to discussing patient care experiences. Topics are not predetermined and allows for flexibility. Ms. Johnson noted her post-clinical conferences are informal and she allows students to take the lead adding useful information and education when necessary (L. Johnson, personal communication, June 24, 2013).Dionne Williams, MSN, RN is a clinical instructor at Prince Georges Community College School of Nursing. She teaches students in the Foundation of Nursing course. The first six weeks of the course, Ms. Williams is with students in the skills lab. The next six weeks students are at a facility for their clinical experience for a total of 8 hours per week. Ms. Williams conducts a post-conference clinical at the end of the second clinical day. The topics to be discussed are predetermined and follow the same schedule of content as the skills lab. During post-clinical conference students discuss their patient experiences, but are expected to relate these experiences to the topic for the day tying in information from the didactic course, previous skill lab learning, and the clinical experience. Ms. Williams added while post-clinical conference topics are predetermined, she has the flexibility in her teaching of these topics (D. Williams, personal communication, June 20, 2013).Dana Duncan, RN, MSN, MPH is a clinical instructor at Howard University School of Nursing and teaches students in the Adult Health I course. This course requires 20 hours of clinical per week. Ms. Duncan conducts a pre and post-clinical conference with her students. During the pre-clinical conference students are given their assignment and briefly discuss the plan of care for their patient with the instructor. The post-conference clinical occurs immediately after the clinical day and consists of students discussing their patients, what they learned and one thing they plan to further research. The topics for post-clinical conference are not predetermined. Ms. Duncan reports she prefers this as it gives her the opportunity to allow students to determine the content based on their patient experiences and then provide impromptu education (D. Duncan, personal communication, June 20, 2013).Kelly Connor, MSN, RN, CNE, CHSE is a clinical instructor at Boise State University School of Nursing. Ms. Connor was contacted after I found an example of her post-clinical conference on YouTube. She teaches the clinical component for second semester junior students. Ms. Connor conducts post-clinical conferences for students online through the Second Life virtual reality world. She utilized special speakers as well as took her students on virtual field trips. For example, students are able to visit real life places through virtual reality such as the American Cancer Society and the Mayo Clinic. Ms. Connor noted last semester she had two clinical groups with 9 students each. She was able to hold clinical post-conferences with both groups through the Second Life virtual reality world. Ms. Connor added she does not have clinical students this semester as she is working on her PhD (K. Connor, personal communication, July 1, 2013).What the Literature Says About Clinical ConferencesWhile only a few strategies utilized by clinical instructors for clinical conferences were explored the options of strategies are vast and unlimited. No matter what strategies a clinical instructor utilize, Billings and Halstead (2012) noted that in order for clinical conferences to be successful and bridge the gap between theory and practice, clinical conferences need to be planned and take into consideration the curriculum, the learner, the purpose, topic and process as well as strategies and methods of evaluation. While some clinical instructors may only utilize post-clinical conferences, O’Connor (2006) recommends that instructors provide some form of pre-clinical conference to ensure students have the most up to date information on their patient so they are prepared to provide adequate care and ensure continuity of care for their patients. It is also noted clinical instructors may find pre-clinical conferences more useful at the beginning of the semester with inexperienced students, but may not find them as necessary as students become more experienced and are more prepared to start the clinical day.Post-clinical conferences provide opportunities for students to share, analyze and evaluate their patient care experiences. The clinical instructor can help enhance student’s critical thinking and clinical reasoning and judgment through asking stimulating and challenging questions to assist students in analyzing, synthesizing and evaluating care (develop higher level cognitive skills). Many instructors are used to telling students what needs to be done, but Gaberson and Oermann (2010) suggests that discussions should be an exchange of ideas between students and instructors. According to Myrick & Yonge (2002), “questions can be used to direct the thinking process, provoke interest, stimulate and challenge the student, influence the social and emotional milieu of the teaching/learning environment, form the basis of research, promote discussion, and evaluate learning” (p.176). While instructors often utilize questioning in clinical post-conferences, they tend to ask low level questions at the knowledge, comprehension and simple application levels of Bloom’s Taxonomy (Hsu, 2007). The art of questioning is a skill instructors must develop in order to stimulate higher level cognitive skills (analysis, synthesis and evaluation). In addition to promoting critical thinking and clinical reasoning (Twibell, Ryan & Hermiz, 2005), the discussions in post-clinical conferences can help students develop cooperative learning and group process skills, enhance communication skills and assess their own learning (Gaberson & Oermann, 2010). Intra-clinical or mid-clinical conferences may be necessary during longer clinical days such as 12-hour shifts to allow students to share their patient care experiences, evaluate care performed thus far and plan how to provide effective care for the rest of the shift (Billings & Halstead, 2010).Copeland (1990) advises that clinical conferences should serve as an opportunity to build and develop student confidence. High levels of stress have been associated with the clinical experience of students. Clinical instructors can decrease the level of stress and develop student confidence by regularly focusing on positive aspects of the clinical experience, positively encouraging students and providing support and by providing productive and constructive feedback. Instructors can provide support by providing praise, kindness and friendliness and providing an environment that promotes listening, respect and openness (Gaberson & Oermann, 2010; Hsu, 2007).Teaching strategies often focus on the cognitive domain. In a study comparing faculty and student perceptions of clinical conferences, Hsu (2007) found most clinical conferences focused on cognitive learning. Clinical conferences and the associated teaching strategies should focus on all the domains of learning: cognitive, affective and psychomotor. Noone (2009) noted nursing education is often compartmentalized. She suggests nursing education should go beyond the three domains of learning and recommends that educators design strategies that integrate learning across the three apprenticeships: the cognitive or intellectual apprenticeship; the skilled-based apprenticeship of practice; and the apprenticeship of ethical, social roles and responsibilities of the profession (Noone, 2009).Wink (2005) suggested effective clinical conferences should have three characteristics. The first is that it consists of a group activity in which all members participate, interact and contribute. The role of the instructor is of facilitator while the role of the student is as participator; however, students should also be expected to initiate discussions. The second characteristic of an effective clinical conference is that it meets the course and clinical goals and objectives. These may be general course objectives such as developing critical thinking or problem-solving skills or may be very specific such as developing specific psychomotor skills. (Wink, 2005). The instructor should link discussions, outcomes, and evaluation strategies to these objectives and goals. The third characteristic of effective clinical conferences is providing an environment in which students share their feelings and attitudes related to patient care. Wink proposes that in order to accomplish this, instructors must make students feel “they face minimal risk of humiliation or embarrassment” (p. 30).While clinical instructors may have specific objectives and goals for clinical conferences, they should be student/learner focused and incorporate innovative teaching strategies. A study by Letizia and Jennrich (1998) and later repeated by Megal, Nelson, Black, Vogel, and Uphoff (2013) found perceptions of the post-clinical conference environment varied among faculty and students. Both studies found innovation in the post-clinical conference environment could be improved. The use of case studies, quizzes, journaling, debates, guest speakers, nursing rounds, patient rounds, storytelling, role play, games and online conferencing have been recommended as creative and innovative strategies that meet the needs of instructors and students. (Gaberson & Oermann, 2010; Glendon & Ulrich, 2004; Letizia, 1998: O’Connor, 2006; Yehle & Royal, 2010). Yehle & Royal (2010) suggests moving post-clinical conferences to another day and time other than immediately after the clinical experience as one way to meet the needs of students. They contend this allows students time think about and reflect on their patient care experiences and allow them to critically analyze and evaluate complex patient situations. Utilizing audio teleconferencing and online conferencing for clinical conferences have been found to meet the needs of students by allowing students to debrief and reflect on experiences during a convenient time and environment for the student; eliminating travel or wait times; reducing barriers such as fatigue after the clinical experience and unavailable meeting space; and providing a relaxed environment that encourages critical thinking and engagement, especially among students who are shy and may not be as likely to participate in face-to-face clinical conferences (Adegbola, 2011; Cooper, Taft & Thelen, 2004). Other literature related to clinical conferences focus on short writing assignments to increase critical thinking (Oermann, 2006); utilizing SBAR in clinical conferences as a way to organize discussions and patient care experiences (Ascano-Martin, 2008); and utilizing post-clinical conferences as a way to introduce and teach quality improvement to nursing students (D’Eramo, 2012). While the literature provides a lot of ideas and suggestions for clinical conferences, I cannot say these are “best practices.” Best practices are strategies that consistently show superior results or outcomes. Despite the fact the clinical conferences are an important component of nursing education, there has been little research on their effectiveness. Numerous articles suggest clinical conferences are instrumental in increasing critical thinking, clinical reasoning and judgment, etc.; however, there is a lack of quantifiable empirical and up to date evidence that the strategies suggested and utilized really enhance student learning. Thus two research questions that need further exploration and would lead to a better understanding of clinical conferences are how truly effective are clinical conferences in enhancing nursing student critical thinking and clinical reasoning and how best can educators evaluate whether clinical conferences truly integrate theory and clinical practice?Recommendations for Effective Clinical ConferencesThe most important recommendation for clinical instructors in implementing effective clinical conferences is to set a positive tone for the clinical experience. The clinical instructor should be supportive and encouraging promoting a positive environment that is conducive to trust, honesty, openness, sharing and discussion. This will translate over to clinical conferences where students can feel comfortable sharing and exploring without fear of judgment by the instructor or without fear of what they say will affect their grade. Clinical instructors should set the expectation of respect. This includes respect for the instructor by students; respect for students by the instructor; and respect between students. This ensures students listen to each other and respect each other points of view and what each student contributes to the group. This means the clinical instructor should not dominate the clinical conference or the discussion. The instructor should emphasis that the clinical conference is an exchange of ideas and encourage participation among the entire group, both instructor and students. This also forces students to take be active participants and take responsibility for their learning.Clinical conferences should not be utilized as a way to continue didactic teaching. Gaberson and Oermann (2010) recommend that they do not serve a substitute for classroom teaching. The clinical instructor should not utilize the pre or post-clinical conference as a way to drill students on their knowledge and skills. This increases stress for students in an already stressful and often overwhelming clinical environment. Rather, the clinical instructor can utilize the clinical conference to evaluate whether students are prepared for clinical practice or whether students are truly connecting what they learn in class with clinical practice. Billings and Halstead (20012) said it best: successful clinical conferences are planned. The clinical instructor should have ideas of possible topics and/or questions for discussion, yet be flexible enough to allow students to address issues they find important or of concern. By having ideas for possible topics, the instructor can ensure the time for the clinical conference is utilized effectively. For example, if students do not have much to contribute, the clinical instructor can have topics that enhance learning or can ask questions that stimulate thinking and further the discussion. When asking questions during the clinical conference, instructors must ensure they are asking higher level questions that encourage deep and critical reflection and thinking. Also, clinical instructors should be alert to teaching and learning moments, whether it is during the clinical conference of during the clinical experience.Instructors should provide constructive criticism to students and never belittle or embarrass them. This is an abuse of power and increase stress and anxiety among students. Clinical instructors should always acknowledge positive actions by the student and if the clinical instructor needs to provide the student with feedback it should be provided in a non-threatening way. Also, if the clinical instructor needs to counsel a student on their actions or behavior, this should not be done in the presence of other students. The clinical instructor should provide students with helpful feedback throughout the clinical experience. This provided feedback should include specific corrective advice and not just information on strengths and weaknesses; it should prioritize areas for improvement; and most importantly, the feedback should be timely. These means feedback is provided within a reasonable time and gives the student time to make the necessary changes and/or improvements.Lastly, instructors should implement creative and innovative strategies for clinical conferences focusing on ways to meet the needs of the course and clinical experience objectives and needs of students. Lastly, clinical instructors must evaluate their clinical conferences and the strategies utilized to determine whether they are meeting the goals of the course and the clinical experience as well as meeting the needs of students. ConclusionNursing is a unique yet complex profession that requires professionals who have a wide knowledge base and range of abilities and skills. Nurse educators are challenged to prepare nurses who meet the competencies to provide effective, safe and individualized patient-centered care. In order to prepare students for this role, nursing educators must utilize innovative and creative teaching strategies to engage students and promote active learning. A previous nursing professor stated, “Theory without practice is useless; practice without theory is dangerous” (Rodgers, 2007). This means theory is not relevant without practice and practice is not effective without theory. In planning and implementing clinical conferences, instructors must ensure they provide an environment of trust and safety encouraging students to analyze, synthesize and evaluate their clinical experiences through teaching strategies that focus on all the domains of learning. Clinical instructors should always strive to utilize learner-focused teaching strategies. Utilizing these strategies in implementing innovative and effective clinical conferences can be a key way of enhancing nursing students’ critical thinking, problem solving, clinical reasoning and judgment and integrating theory into practice. In addition, an important component of implementing clinical conferences is ensuring clinical instructors continually evaluate the strategies utilized to meet the needs of the course and clinical experience, but most importantly, to meet the needs of students.ReferencesAdegbola, M. (2011). Taking learning to the learner: Using audio teleconferencing for postclinical conferences and more. Creative Nursing, 17(3), 120-125.Ascano-Martin, F. (2008). Shift report and SBAR strategies for clinical postconference. Nurse Educator, 33(5), 190-191. doi: 10.1097/01.NNE.0000334779.90395.67Billings, D.M. & Halstead, J.A. (2012). Teaching in Nursing: A guide for faculty (4th ed.). St. Louis: Elsevier Health SciencesCandela, L. & Bowles, C. (2008). 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