Our integrated multi-patient simulations are designed to integrate learning from the nursing curriculum; and, as a result, provide a picture of the strengths and weaknesses of nursing curricula. Consistent with current research related to employer concerns of new graduate nurse performance by Kavanagh & Szweda (2017), our sims show that there are serious issues related to clinical learning experiences, and that schools of nursing must do a better job of preparing students with the necessary skills needed for beginning entry-level nursing practice. Graduating students consistently told us that they didn't have opportunities during clinical learning experiences to think on their own, develop critical thinking and clinical decisions making skills, communicate with providers and the healthcare team, document care in the EHR, or perform psychomotor skills. We believe this is occurring for many reasons because of changes in the model for clinical education which has become much more observational in nature. I'll talk about that more in another blog.
We see weaknesses across the board, no matter whether students are considered strong or weak by their faculty. Students may have good test scores and grades, but since they don't get opportunities to develop their skills (including critical thinking and communication) in practice, they often aren't able to put everything together. This is creating a crisis in nursing education putting more and more of the training responsibility on employers to support new nurses to develop skills they should have mastered in school. There is no doubt a preparation-practice gap.
Some of the areas of weakness we have consistently seen among senior students are:
Critical thinking. Students have difficulty using data (assessment data, EHR data, disease process data, etc.) to set priorities and determine the most unstable patients in their assignment. While students are generally strong in physical assessment skills, they have difficulty with looking to other sources of data, with interpretation of data, with differentiating relevant from non-relevant information, with clustering data, and, as a result, with acting on data.
Nursing care. A problem also discussed in the literature is the growing focus on the medical model in nursing curricula (also a subject for a future blog). Students are very often focused on the medical diagnosis to the exclusion of holistic nursing care, thus showing they do not have a good grasp of the nursing process (or clinical reasoning process). Physical assessment (where students are stronger) is often a stopping point with no continuation on to outcomes. Thus, nursing interventions are more based on the medical treatment plan than on nursing care. And, while physical assessment skills may be strong, students are not as strong with focused assessments. Focused assessments require critical thinking and understanding of the disease process.
It is obvious that patient teaching is a focus for students. But without that teaching being in a holistic plan of care, it generally relates primarily to the medical plan of care. This also leads to weak or absent discharge planning. There is a tendency to pass off discharge planning to Social Work. We remind students that while social workers certainly have a crucial role in this process, social workers are not responsible for nursing care.
Communication. Students are compassionate, and we are gratified that they continuously validate this to us. But, they tend to lack skills in active listening and therapeutic use of self. It takes considerable practice to achieve growth in these areas and students are not getting adequate opportunities in their clinical experiences. This is crucial to the core of nursing practice, and it should be a focus in the curriculum, even if other skills are not entirely attainable while in school. There also needs to be more emphasis on the environment and creation of a healing environment.
Students are often not competent to do handoffs/SBAR reports to providers or at change of shift. During handoff, we have routinely seen students provide incomplete information, and they are unable to differentiate between relevant background information and information not needing to be reported (critical thinking). They do not provide a complete picture; they may describe a patient as short of breath, but do not report vital signs, assessment data, or actions taken. Handoffs are typically disorganized and vital information needed for patient safety is often missing.
Documentation. Students report that they have not had much opportunity to document care in the clinical arena. This is understandable in today's healthcare environment. But, this becomes a responsibility for schools to pick up the slack. Documentation for the most part is grossly lacking, such as vital signs for trending data, special nursing care needs (Braden scale, diabetic foot care assessment, etc.) and effectiveness of care.
Fundamental skills (psychomotor skills). Students are uncomfortable with most tasks/skills. A basic level of competence is necessary or it interferes with other areas, such as critical thinking. Employers should not have to teach basic skills. Certainly the lack of competence in skills is a result of a more observational clinical experience, but there are ways to develop and maintain competence through simulation experiences. Research shows that once students learn skills (e.g., in their fundamentals course), they need continued practice in order to maintain those skills (Sawyer, et al., 2015). They may have learned the skills but cannot maintain them without practice. They can both build and maintain skills if they are involved in regular, well-designed simulation activities.
Students have weaknesses in IV maintenance, IV meds, medication calculations (such as calculations for weight based heparin or IV drip rates), IM landmarks, needle sizes and correct syringes, accessing drug information (i.e., they use smart pumps without looking up information, or call the pharmacy, or use free apps such as Google which do not provide complete information). Most students have never transferred or assisted with transfers of patients from stretcher to bed or bed to chair, etc. They do not properly make beds (do not pay attention to insuring that there are no wrinkles in bed linens). And, they are weak with sterile technique, as well as donning and doffing Personal Protective Equipment (PPE). Finally, we consistently saw multiple violations of hand washing principles.
We believe that the lack of psychomoter skills competency interferes with students' learning in many areas, and needs to be addressed. But, greater than that, our concerns are about the overall weaknesses of students in general. This is consistent with employer concerns, and indicates a need for re-evaluation of nursing curricula and clinical experiences. To be fair, the National Council of State Boards of Nursing and the American Association of Colleges of Nursing have admitted that there is a preparation-practice gap. But, in our view, these organizations pass this off entirely to employers by calling for residency programs for new graduate nurses as the solution to this problem. While we strongly support the need for residency programs, we believe there is much more that colleges of nursing can do to address this issue. The observational nature of clinical experiences may be here to stay. But, it doesn't have to shift more and more of the training to employers. A new clinical teaching model is needed in nursing education. But, more than that, students need relevant, safe, simulated nursing experiences that focus on the centrality of nursing, build critical thinking and clinical decision-making skills, and truly focus on meeting the outcomes intended for prelicensure nursing education. Our integrated simulations provide this experience.
References
Kavanagh, J. M., & Szweda, C. (2017). A Crisis in Competency: The Strategic and Ethical Imperative to Assessing New Graduate Nurses' Clinical Reasoning. Nursing Education Perspectives, 38(2), 57-62.
Sawyer, T., White, M., Zaveri, P., Chang, T., Ades, A., French, H., ... Kessler, D. (2015, August). Learn, See, Practice, Prove, Do, Maintain: An Evidence-Based Pedagogical Framework for Procedural Skill Training in Medicine. Academic Medicine, 90(8), 1025-1033.