Nurse Education in Practice xxx (2014) 1e5
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Learning and teaching in clinical practice
Clinical Coaching e An innovative role to improve marginal nursing students' clinical practice Moira F. Kelton* Grad Cert Clinical Education, School of Nursing and Midwifery, Flinders University of South Australia, GPO Box 2100, Adelaide, SA 5001 Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 11 June 2014
In order for undergraduate nursing students to demonstrate their ability to achieve the required level of competency with practice they must be able to integrate both the clinical skills and knowledge that are pivotal to safe and competent nursing practice. In response to ongoing concerns about students' level of competency expressed by the supervising clinical staff, one School of Nursing and Midwifery created a Clinical Coach (CC) role. The purpose of this paper is to present the data collected including outcomes achieved and the coaching strategies used when a CC role was implemented to support and develop nursing practice for the marginal performer or ‘at risk’ student. A literature review of the application of coaching to nursing, a detailed analysis and discussion of the outcomes identified from auditing of collected data and the specific coaching strategies that resulted in successful outcomes for students is presented. This model of Clinical Coaching for nursing students could readily be adopted by other Schools of Nursing and Midwifery. This account of the regime of coaching practices may also offer a transferable, adaptable and flexible approach for other health professions who require their undergraduate students to complete clinical placements in preparation for professional practice. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Coaching Clinical placement Skills development Nursing students
Introduction Clinical placement experience is an integral aspect of practice development for undergraduate nursing students undertaking a Bachelor of Nursing degree in Australia. Students undertake multiple placements across various health agencies. Development of nursing practice requires the synchronicity of both knowledge application and clinical skills and students must demonstrate ability to integrate these professional requirements of the Registered Nurse (RN) for which they are being prepared. In Australia, this requires students to demonstrate the ability to meet the Nursing and Midwifery Board (NMBA) competencies (Australian Nursing & Midwifery Council, 2006) to that of a beginning level RN standard by completion of their degree. The majority of nursing students is able to develop and to meet these expectations and successfully integrate increasingly complex skills with practice knowledge as they progress throughout the year levels. Some students, however, fail to meet the expected levels of competency when undertaking nursing practice in the clinical setting. In response to an increasing number of students who had practice deficits identified when they were in the clinical setting, one School
* Tel.: þ61 8 82013273; fax: þ61 8 82968902. E-mail address: moira.kelton@flinders.edu.au.
of Nursing and Midwifery implemented a series of practice development strategies. The appointment of an academic in a Clinical Coach (CC) role the subject of this paper was one of these strategies. The purpose of this paper is to present the data collected including outcomes achieved and the coaching strategies used when the CC role was implemented to support and develop nursing practice for the marginal performer or ‘at risk’ student. The CC provided opportunity for early intervention and guidance to students identified and referred who required additional support to build confidence, to develop understanding and to increase ability to demonstrate the core attributes of practice and so improve their clinical practice skills. The term skills throughout this paper will refer to the collective practices of nurses that require them to perform psychomotor technical clinical skills, demonstrate effective communication skills, show ability to time manage and be able to plan and prioritise nursing care for their patients. ‘Coaching’ is a term borrowed from sporting philosophy. Sporting philosophy is underpinned by cognitive psychology, which seeks to understand the nature of human intelligence and how this works (Anderson, 1985). In more recent times the term ‘coach’ has emerged as a contemporary term used by ‘executive or life coaches’ who are often engaged by business management to improve productivity or equip individuals with the skills that result in success (Savage, 2001). Coaches follow established codes of behaviour that include having realistic and attainable expectations,
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Please cite this article in press as: Kelton, M.F., Clinical Coaching e An innovative role to improve marginal nursing students' clinical practice, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.06.010
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M.F. Kelton / Nurse Education in Practice xxx (2014) 1e5
ensuring all players know the rules, earning players' respect, and giving praise as well as being personally committed (Pyke, 1991). The term ‘coach’ as it relates to the CC role discussed throughout this paper, is synonymous with its accepted meaning within the sporting world as one who trains through the processes of instruction and of giving advice (Pyke, 1991). Coaching in relation to clinical education involves ‘the interactive, interpersonal processes through the acquisition of appropriate skills, actions and abilities that form the basis of professional practice’ (Morton-Cooper and Palmer, 1993, p 47, cited in Grealish, 2000 p. 231). The CC role involved adaptation of sporting tenets or principles to the clinical practice milieu and was underpinned by six coaching principles. These principles were to show each student respect; seek to develop their potential; communicate effectively; provide specific feedback; use goal setting to motivate and provide appropriate challenges (Martens, 1997; Crisfield et al., 1996). Coaching sessions were focused on development of student's nursing practice skills affording them opportunity to improve their practice and meet the standards of clinical competency of safe practice. The CC provided support and advice to students and encouraged students to access wider support services provided by the University if necessary. In addition, the CC role included responsibility for contributing to the planning and evaluation of undergraduate course work through direct involvement with curriculum development. The CC tracked all coaching referrals and student progress. The coaching data-base provided the means by which to track the outcomes of the Clinical Coach role over the initial 9 semesters it was implemented. An audit of this data together with a review of literature around coaching for nursing practice development will be presented, analysed and discussed in this paper. Lessons learnt to date about development of clinical practice and the specific coaching strategies that resulted in successful outcomes for referred students will be presented. Patterns and trends that emerged have enabled the CC to make recommendations to the wider School community and of implementing a range of strategies to further support the marginal or ‘at risk’ undergraduate nursing student. Literature review There is extensive literature available in relation to nursing education of students in the clinical environment. Much of this literature relates to aspects of clinical education including the supervision of students, the role of clinical educators and facilitators, university and hospital collaboration, the evaluation of students' clinical competence and the theoryepractice gap. A data-base search was undertaken across several data-bases including CINAHL; Medline and Proquest data-bases using the key words coaching; clinical placement, skills development and nursing students. The literature presented here will only address the nursing literature around coaching when undertaken as a strategic approach for development of nursing practice. Few primary research studies were uncovered and much of the literature around coaching in nursing was simply a descriptive or opinion-based paper. Most literature around the issue of coaching in nursing relates to the staff development and not the students. Research papers that looked at post graduate and/or master's programme students or peer teaching models that called it coaching have not been included as the CC role presented in this paper was only for undergraduate nursing students. Several articles reviewed, discuss the merits of coaching as an effective strategy for nurse managers to adapt in order to promote learning and to develop self-awareness amongst nursing staff. As far back as the 1990s Pethigal (1991), Haas (1992), Cole (1994) and Whyte (1997) all determined that coaching principles could be
used to support staff development. Haas (1992) provided a coaching framework and presented the techniques and central principles essential to coaching that involved six phases including observing and auditing, analysis, discussion, channelling, delegating and feedback (Haas, 1992, p 56). According to Cole (1994), coaches needed to possess certain skills that included being credible, patient, supportive, flexible and respectful of the learner. Cole (1994) concluded that the coach required keen observation and a high level of interpersonal skills, an understanding of the principles that feedback should be descriptive and not judgemental and knowledge of the principles of adult learning and ability to apply them. Whyte (1997) concluded coaching methods could be used to help individuals to develop the ability to learn, as opposed to having to teach them, in a way that fostered their ability to maximise their own performance. Hallett's (1997) phenomenological interpretive study examined the relevance of Schon's (1987) theories of coaching to nursing education in the UK. Hallett's study focussed on aspects of Schon's theories that could be utilised by community based nurses who undertook the supervision of college based nursing students. Schon's (1987) theories consist of the application of three types of coaching within the studentecoach relationship. These included “Joint Experimentation” in which the student and coach work, discuss and debate together, “Follow Me” a process by which the student learns to imitate the coach and “Hall of Mirrors” in which insight of practice facilitates learning (Schon, 1987). Hallett (1997) presented learning as a sequence of events composed of seven stages and concluded that knowledge and understanding grew out of practice for both students and supervisors. These seven stages included encountering reality, having a go, gaining confidence, thinking through and understanding, developing ideas, being independent and being assessed (Hallett, 1997, p106). Hallett's (1997) work was an exceptional study that provided an educational pedagogy that enhanced outcomes for nursing students undertaking placement using a coaching philosophy developed by Schon (1987) that she showed had real relevance in the clinical education of nursing students. Kowalski and Casper (2007) set out to gain a better understanding of the potential of coaching in nursing by drawing on the extensive study of clinical nursing practice in the clinical environment undertaken by Benner. Benner's work, published in 1984, was the culmination of descriptive research of nursing practice that applied the Dreyfus model of five distinctive levels of skill acquisition to unpack the notion of expertise in nursing practice. Benner (1984) was instrumental in highlighting how nurses develop in their nursing practice and how that development is paraleled with their gaining of ongoing experience. Such a framework provides a sound pedagogical base for understanding how skills acquisition, the primary aim of coaching, develops. Kowalski and Casper (2007) concluded that in order to be effective, the coach must have the experience of practice, that is be advanced or expert in their own practice, so as to best provide opportunity to others and assist staff in developing ability to integrate theoretical knowledge and so enhance and develop their clinical practice. Nursing literature uses several terms to describe specific support that can be afforded students including coaching, mentoring and facilitation to name a few. Sherman (2006) examined the impact of coaching across generations as in an unprecedented situation, four generations now make up the current nursing workforce. Sherman (2006) evaluated how the generations differ in their attitudes and behaviours towards coaching and mentoring, terms incorrectly used interchangeably throughout nursing literature, and showed that these terms mean different things to the different generations. In making a distinction for this paper, between coaching and mentoring, coaching is task oriented with a focus on
Please cite this article in press as: Kelton, M.F., Clinical Coaching e An innovative role to improve marginal nursing students' clinical practice, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.06.010
M.F. Kelton / Nurse Education in Practice xxx (2014) 1e5
concrete issues, it is short-term and is performance driven whilst mentoring is relationship-oriented and is long-term (Fielden et al., 2009). Specific literature exploring and discussing nursing literature around coaching undertaken as a strategic approach for development of nursing practice has been presented. Very little literature undertaking research around the Clinical Coaching of nursing students was uncovered. Hallett's (1997) phenomenological work was primary research work that evaluated the application and use of coaching principles and strategies to develop and improve nursing students' clinical practice. Much of the grey literature identified supports the benefits and nuances of using a coaching model including various coaching strategies for the development of clinical staff. No literature was uncovered that explored the outcomes of a Clinical Coach as a targeted academic role to purposively improve and develop the marginal or ‘at risk’ undergraduate nursing student's clinical practice. The uniqueness of this academic role warranted evaluation of what it could achieve. Results from the audited data collected during the initial 9 semesters following the appointment of the CC in one School of Nursing and Midwifery are presented in the following section. Results/methods Auditing is as an accepted method for conducting analysis of data and is useful for examining and determining through objective evidence the effectiveness of implementation of a particular planned activity for a stated purpose (Closs and Cheater, 1996). The data-base tracked measurable evidence and outcomes for all students referred to the CC with identified practice deficits. Specifically the data tracked included the students' year level; reason(s) or issues prompting the referral; outcomes following coaching sessions and English Second Language (ESL) status. Confidentiality was maintained at all times and all data entered depersonalised so as to ensure students' identity remained protected in keeping with ethical responsibilities of the CC. A total of 188 students was referred for assessment by the Clinical Coach comprising 121 third years, 64 second years and 3 first years. Table 1 is included as a summary of the collated data. Clinical Coaching achieved good outcomes with 156/188 students going on to successfully complete clinical placement and to pass their program. Following the initial coaching assessment 9 students were deemed by the Clinical Coach as having a satisfactory, safe level of practice and so were not accepted for coaching and their academic coordinators informed. Coaching was not punitive as the performer wishing to engage is considered essential to achieving successful outcomes (Crisfield et al., 1996). When 2 students did not wish to undertake coaching they were not forced to and were
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followed up instead by their academic coordinator. Some students elected to withdraw themselves from the program for various reasons mostly relating to personal situations impacting on their study or ability to set aside the time required to attend clinical placement. Academic coordinators withdrew 3 students from their clinical placement when it became obvious these students could not meet academic requirements of the topic. Table 1 summarises collected data following implementation of the CC role over 9 semesters. Poor professional communication skills, in fact, was the most common reason identified by supervising clinical staff that had prompted referral of the student for assessment by the CC. ESL was found to be a significant factor in the number of referrals around communication with 151/188 students referred during the period presented having an ESL background. This statistic included both international and domestic residents with an ESL background as their issue was with language difficulties, not residency status. Even following extensive coaching, one student remained unsafe and was deemed a risk to patients and staff due to her very poor communication skills compounded by her ESL background. The student was counselled and advised to undertake remedial English language classes. She was removed from clinical placement and recorded as a fail in the coaching data-base. Clinical Coaching involved a five-step systematic approach that included comprehensive assessment; demonstration of skills; supervision of one to one remedial practice sessions; provision of feedback and finally debriefing. Case based scenarios and quizzes reflecting the particular clinical environment where the student had been undertaking placement were also used during this initial coaching assessment. Students were set a range of activities that assessed their psychomotor skills, their ability to plan and prioritise nursing care and the effectiveness of their communication skills. The Bondy Scale (see Appendix 1) and a Level of Competence Tool (see Fig. 1) used during this initial assessment enabled the CC to determine the need for coaching identify student's specific practice deficits. Students who were assessed in the assessment session as a 1 or 2 using the Bondy Scale (see Appendix 1) and as either consciously competent (stage 3) or unconsciously competent (stage 4) against the competency gradient tool above did not require coaching. These are the students who following coaching assessment were not accepted for coaching (see Table 1) and their academic coordinators subsequently informed. The consciously incompetent student as identified by Lake and Hamdorf (2004) and Peyton (1998) is aware of their practice deficits and was found to be the group of students who most actively engaged in the coaching process. The unconsciously incompetent student, however, were the most difficult to coach. Unconsciously incompetent students were found by the CC
Table 1 Clinical Coach data. Statistics: Semesters 1e9
Total student referrals Third year Second year First year English second language Outcome of coaching Passed clinical placement Student withdrew self from program Withdrawn by other Failed Not accepted for coaching Total
S1
S2
S3
S4
S5
S6
S7
S8
S9
Totals
12 8 4 0 10
20 12 8 0 19
11 7 4 0 9
26 24 2 0 25
24 12 12 0 21
26 16 10 0 20
13 7 6 0 10
31 23 8 0 22
25 12 10 3 15
188 121 64 3 151
8 4
17 2
10 1
22 2
22 0
18 5
12 1
25 2
22 2
156 19
0 0 0 12
0 0 1 20
0 0 0 11
1 0 1 26
0 1 1 24
1 0 2 26
0 0 0 13
1 0 3 31
0 0 1 25
3 1 9 188
Stage1. Unconsciously Incompetent
Student does not realize what they don’t know
Stage 2. Consciously Incompetent
Student realises they don’t know Student realises they know and can do with great thought
Stage3. Consciously Competent Stage 4. Unconsciously Competent
Student does without thought
(Adapted from Lake and Hamdorf, 2004; Peyton, 1998)
Fig. 1. Level of competence tool.
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M.F. Kelton / Nurse Education in Practice xxx (2014) 1e5
to lack insight into their poor practice and often failed to recognise their own practice limitations even acting outside their scope of practice. With the potential for these students to cause harm to patients the CC recommended to academic coordinators that the action plan was to suspend these students from clinical placement until they were able to demonstrate a safe level of clinical practice in the simulated laboratory environment. Communication deficits and other reasons that prompted referral to the coach by clinical facilitators warrant further discussion. These issues together with discussion and exploration of the specific coaching strategies applied to manage and develop the marginal performer or ‘at risk’ students' nursing practice will be presented in the Discussion section. Discussion Students who are not proficient in their practice tend to be slow and uncoordinated with skills and lack confidence in their clinical practice (Bondy, 1983). These students take a long time to get through the tasks and then have little or no time for reflection on the wider implications of their nursing practice. Such uncoordinated care often requires frequent prompting from staff and when coupled with a lack of proficiency with technical clinical skills results in unsatisfactory practice. Characteristics of the marginal performer as identified by Bogo and Vayda (1998) and further developed by Cooper et al. (2003) include the inability to link theory and practice; of being task oriented, requiring constant direction and prompting and of lacking ability to reflect on practice regarded as critical skills for practice development (Ervin, 2005; Whyte, 1997). Poor practice by marginal performers gets noticed by supervising clinical staff and when reported to the Clinical Facilitator whose role it is to ensure our nursing students meet both university and professional expectations during clinical placement prompted referral to the CC. Skills development to a proficiency level requires more than just performing of the actual task as it requires integration of knowledge, skill and communication (Lake and Hamdorf, 2004). Coaching was undertaken in a purpose-built skills laboratory using standardised patients and high and medium fidelity manikins. Skills sessions were contextualised with the students providing comprehensive nursing care for patients in a simulated environment designed to reflect their relevant clinical placement practice setting. The reasons students had not mastered specific psychomotor skills varied. Some students had not been taught the correct method to begin with and others had been afforded limited opportunity to practice the more complex skills. Many students had been influenced by poor practice they had observed or been taught during their clinical experience placements, whilst in some instances the students simply lacked the fine motor skill required to perform psychomotor skills. Poor communication, the most common reason for referral to the coach, has far-reaching implications for the student themselves, the clinical staff who provide supervision and for the patients to whom that student is responsible for providing nursing care. Many of the students referred for coaching were involved in critical incident or near-miss situations including medication errors. Coaching sessions sought to correct students' communication deficits by incorporating activities including interpreting medication charts accurately and how to seek clarification from supervising clinical staff if unsure. Evidence has shown that cultural and linguistic diversity (CALD) students require higher levels of support when undertaking clinical placements to ensure they perform at the expected level (Harvey et al., 2013). The high numbers of ESL referrals to the CC became instrumental in the wider school community seeking out additional practice development strategies to
support CALD students. The result was the development of a Clinical Communication Programme (CCP) a tool that assisted students to understand and apply professional clinical language and jargon common to the clinical environment and to be able to document accurately and to be computer literate. Other practice deficits prompting referral included an inability to provide fundamental or basic nursing care; failing to implement effective time-management skills or lacking ability to plan and prioritise nursing care. Following coaching sessions that involved demonstration, instruction and guidance, many of the students not only returned to complete placement but also went on to get excellent clinical reports. What became evident was that the earlier in the placement the student was referred for coaching the better the end outcome. Supervising clinical staff noticed when practice improved, in some instances it was a vast improvement, and this then facilitated their willingness to allow the student to engage more fully in patient care. This had a flow on effect as it resulting in the student's self-confidence growing which in turn further enhanced their clinical practice capabilities. Confidence and motivation instilled through coaching processes results in improved nursing practice (Grealish, 2000). The coaching process was underpinned by coaching approaches earlier identified by Pethigal (1991), Haas (1992) and Cole (1994) especially the use of assessment, observation, analysis and discussion. Feedback was used by the coach following assessment and observation in order to facilitate analysis and discussion. Specific feedback aimed at developing reflective practice skills was a critical strategy utilised by the CC to support student's ability to identify their practice deficits. Specific feedback is feedback that is directed at behaviour that is changeable using an informative, positive, corrective process that provides precise detail about what the student should do in order to solve or correct a problem (Martens, 1997). According to Ende (1983), without feedback mistakes go uncorrected and good performance is not reinforced. A determination of the students' level of maturity was required when giving feedback so that as Whyte (1997) had discussed the recipient's ability to identify their own practice deficits was fostered and helped them assume responsibility for their own learning. Coaching is purposeful and is underpinned by educational philosophies that by design seek to ensure learning occurs. Debriefing, with its military origins, is the term used for a description of a situation that moves beyond talking to the process through analysis and development of strategies for future application in a similar situation (Fanning and Gaba, 2007). Debriefing was used by the CC to generate discussion and analysis that creates insight and awareness of practice that as Hallett (1997) showed facilitates learning. Third years, in particular, need to have moved beyond the stages of ‘noticing’ or ‘making sense’ of clinical placement to a level where they are beginning to ‘make meaning’ of their experience (Martin and Fleming, 2010). Debriefing provided a way for the CC to encourage students to articulate clinical rationales for the nursing practice they implemented. As students became more confident in their ability to provide rationales for practice their ability to selfreflect also improved.
Limitations This study is limited in that it is based on only 9 semesters of data collection. It would be remiss, not to acknowledge that students would have weighed up the risk of failing their clinical component of topics when making their decision to attend. A longitudinal study and evaluation of qualitative data as distinct from a simple audit would provide a more effective way to continue to gather evidence of the impact of the role of Clinical Coach.
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Conclusions/recommendations Clinical Coaching begins with referral of a student whose clinical nursing practice has raised concerns amongst the supervising clinical staff. Coaching involves assessment of the students' competence and performance. Coaching strategies purposively designed to build confidence, develop understanding and increase ability to demonstrate the core attributes of practice are applied. The purpose of this paper was to present the outcomes achieved through these coaching strategies when a Clinical Coaching role was implemented to support and develop nursing practice for the marginal performer or ‘at risk’ student. A literature review around coaching in nursing examined its application when seeking to enhance performance. Data collected over nine semesters of the Clinical Coach role was presented and showed that following coaching sessions high numbers of the students went on to successfully complete their clinical placement. Communication inadequacies steeped in ESL issues was the most common reason for referral. Opportunity exists for further research into adoption of this model of Clinical Coaching by other Schools of Nursing and Midwifery. Further research to evaluate the application of specific coaching strategies and explore coaching practices that may offer a transferable, adaptable and flexible approach for other health professions who require undergraduate students to complete clinical placements is warranted.
Appendix 1. The Bondy Scale
1 Independent & excellent performance Demonstrates an excellent understanding of knowledge underpinning practice. Very coordinated, proficient and confident in technical clinical skills. Professional and caring at all times. Excellent effective interpersonal communication skills with patients and staff. Very good ability to synthesise theory and practice with minimal prompts. Very well developed clinical reasoning skills. The student deserving of a score of 1 will require minimal prompts for thinking or actions from staff. 2 Infrequently assisted & good performance Demonstrates a sound understanding of knowledge underpinning practice. Coordinated, proficient and confident in technical skills. Professional and caring at all times. Good effective interpersonal communication skills with patients and staff. Good ability to synthesise theory and practice with infrequent prompts. Good clinical reasoning skills. The student deserving of a score of 2 will require some prompts for thinking or actions from staff. 3 Assisted & satisfactory performance Demonstrates a satisfactory understanding of knowledge underpinning practice. Coordinated, proficient and confident in most technical skills. Will usually consult appropriate resources prior to asking for assistance. Professional and caring at all times. Appropriate interpersonal communication skills at all times. Satisfactory ability to synthesise theory and practice requiring prompts at times. Satisfactory clinical reasoning skills. The student deserving of a score of 3 requires and seeks prompts for thinking or actions from staff. 4 Dependent & unsatisfactory Deficit in knowledge underpinning practice. Requires frequent prompting to elicit knowledge. Uncoordinated, unconfident and lacks proficiency in basic technical skills. Professional conduct and caring not consistently demonstrated. Frequently demonstrates ineffective interpersonal communication skills. Inability to synthesise theory and practice even with frequent prompting and support.
5
(continued ) The student deserving of a score of 4 will require frequent verbal and physical direction from staff. Adapted from Bondy (1983) Journal of Nursing Education. 22(9); University of South Australia (1999) Bachelor of Nursing Clinical Assessment Form; Flinders Medical Centre Performance Review Graduate Nurse.
References Anderson, J., 1985. Cognitive Psychology and Its Implications, second ed. W.H. Freeman and Company, U.S.A. Australian Nursing & Midwifery Council, January 2006. Nursing and Midwifery Board of Australia (NMBA) National Competency Standards for the Registered Nurse, fourth ed. Canberra. Benner, P., 1984. From Novice to Expert e Excellence and Power in Clinical Nursing Practice. Addison-Wesley Publishing Company, Inc, California, USA. Bogo, M., Vayda, E., 1998. The Practice of Field Instruction in Social Work: Theory and Process, second ed. University of Toronto Press, Toronto, Canada. Bondy, K., 1983. Criterion-referenced definitions for rating scales in clinical evaluation. J. Nurs. Educ. 22 (9), 376e382. Closs, S.J., Cheater, F.M., 1996. Audit or research e what is the difference? J. Clin. Nurs. 5, 249e256. Cole, J., September/October 1994. Coaching as a framework for developing staff in the operating room. Can. Oper. Room Nurs. J. 12 (3), 37e39, 41. Cooper, L., Orrell, J., Bowden, M., 2003. Workplace Learning Management Manual. Flinders Press, Flinders University, Adelaide, Australia. Crisfield, P., Houlston, D., Simpkin, A. (Eds.), 1996. Coaching Sessions; A Guide to Planning and. Goal-Setting. The National Coaching Foundation, Headingley, Leeds, UK. Ende, J., 1983. Feedback in clinical medical education. JAMA 250, 777e778. Ervin, N., November/December 2005. Clinical Coaching: a strategy for enhancing evidence-based nursing practice. Clin. Nurse Spec. 19 (6), 296e301. Fanning, R.M., Gaba, D.M., Summer 2007. The role of debriefing in simulation based learning. Simul. Healthc. J. Soc. Simul. Healthc. 2 (2), 115e125. Fielden, S.L., Davidson, M.J., Sutherland, V.J., 2009. Innovations in coaching and mentoring: implications for nurse leadership development. Health Serv. Manage. Res. 22 (2), 92e99. Grealish, L., May 2000. The skills of coach are an essential element in clinical learning. J. Nurs. Educ. 39 (5), 231e233. Haas, S., 1992. Coaching-developing key players. J. Nurs. Adm. 22 (6), 54e58. Hallett, C., 1997. Learning through reflection in the community: the relevance of Schon's theories of coaching to nursing education. Int. J. Nurs. Stud. 34 (2), 103e110. Harvey, T., Robinson, C., Frohman, R., 2013. Preparing culturally and linguistically diverse nursing students for clinical practice in the health care setting. J. Nurs. Educ. 52 (7), 365e370. Kowalski, K., Casper, M., AprileJune 2007. The coaching process e an effective tool for professional development. Nurs. Adm. Q. 31 (2), 171e179. Lake, F., Hamdorf, J., 20 September 2004. Teaching on the Run Tips 5: teaching a skill. MJA 181 (6), 327e328. Martens, R., 1997. Successful Coaching. “A Publication of the American Sport Education Program and the National Federation Interscholastic Coaches Association”. Library of Congress Cataloguing-in-Publication Data, USA. Martin, A., Fleming, J., 2010. Cooperative education in outdoor education. Aust. J. Outdoor Educ. 14 (1), 41e48. Morton-Cooper, A., Palmer, A., 1993. Mentoring and Preceptorship: A Guide to Support Roles in Clinical Practice. Blackwell Science Ltd, Oxford, UK. Pethigal, P., Spring 1991. Coaching for success and improved performance. Gastroenterol. Nurs. 13 (4), 231e233. Peyton, J.W.R., 1998. Teaching and learning in medical practice. The learning cycle. In: Peyton, J.W.R. (Ed.), Teaching and Learning in Medical Practice. Manticore Europe Limited, Rickmansworth, UK. Pyke, F. (Ed.), 1991. The Role of the Coach e Better Coaching e Advanced Coach's Manual. Australian Coaching Council Incorporated, ACT. Savage, C., JulyeAugust 2001. Executive coaching: professional self-care for nursing. Nurs. Econ. 19 (4), 178e182. Schon, D., 1987. Educating the Reflective Practioner: towards a New Design for Teaching and Learning in the Professions. Jossey-Bass Inc., Publishers, San Francisco, USA. Sherman, R., 2006. Leading a multi-generational nursing workforce: issues, challenges and Strategies. OJIN: Online J. Issues Nurs. 11 (2) http://dx.doi.org/ 10.3912/OJIN.Vol11No02Man02. Manuscript 2. Whyte, L., March 1997. Coaching for change: realising the potential for nursing. Nurs. Manag. 3 (10), 12e13.
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Learning and teaching in clinical practice
Clinical Coaching e An innovative role to improve marginal nursing students' clinical practice Moira F. Kelton* Grad Cert Clinical Education, School of Nursing and Midwifery, Flinders University of South Australia, GPO Box 2100, Adelaide, SA 5001 Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 11 June 2014
In order for undergraduate nursing students to demonstrate their ability to achieve the required level of competency with practice they must be able to integrate both the clinical skills and knowledge that are pivotal to safe and competent nursing practice. In response to ongoing concerns about students' level of competency expressed by the supervising clinical staff, one School of Nursing and Midwifery created a Clinical Coach (CC) role. The purpose of this paper is to present the data collected including outcomes achieved and the coaching strategies used when a CC role was implemented to support and develop nursing practice for the marginal performer or ‘at risk’ student. A literature review of the application of coaching to nursing, a detailed analysis and discussion of the outcomes identified from auditing of collected data and the specific coaching strategies that resulted in successful outcomes for students is presented. This model of Clinical Coaching for nursing students could readily be adopted by other Schools of Nursing and Midwifery. This account of the regime of coaching practices may also offer a transferable, adaptable and flexible approach for other health professions who require their undergraduate students to complete clinical placements in preparation for professional practice. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Coaching Clinical placement Skills development Nursing students
Introduction Clinical placement experience is an integral aspect of practice development for undergraduate nursing students undertaking a Bachelor of Nursing degree in Australia. Students undertake multiple placements across various health agencies. Development of nursing practice requires the synchronicity of both knowledge application and clinical skills and students must demonstrate ability to integrate these professional requirements of the Registered Nurse (RN) for which they are being prepared. In Australia, this requires students to demonstrate the ability to meet the Nursing and Midwifery Board (NMBA) competencies (Australian Nursing & Midwifery Council, 2006) to that of a beginning level RN standard by completion of their degree. The majority of nursing students is able to develop and to meet these expectations and successfully integrate increasingly complex skills with practice knowledge as they progress throughout the year levels. Some students, however, fail to meet the expected levels of competency when undertaking nursing practice in the clinical setting. In response to an increasing number of students who had practice deficits identified when they were in the clinical setting, one School
* Tel.: þ61 8 82013273; fax: þ61 8 82968902. E-mail address: moira.kelton@flinders.edu.au.
of Nursing and Midwifery implemented a series of practice development strategies. The appointment of an academic in a Clinical Coach (CC) role the subject of this paper was one of these strategies. The purpose of this paper is to present the data collected including outcomes achieved and the coaching strategies used when the CC role was implemented to support and develop nursing practice for the marginal performer or ‘at risk’ student. The CC provided opportunity for early intervention and guidance to students identified and referred who required additional support to build confidence, to develop understanding and to increase ability to demonstrate the core attributes of practice and so improve their clinical practice skills. The term skills throughout this paper will refer to the collective practices of nurses that require them to perform psychomotor technical clinical skills, demonstrate effective communication skills, show ability to time manage and be able to plan and prioritise nursing care for their patients. ‘Coaching’ is a term borrowed from sporting philosophy. Sporting philosophy is underpinned by cognitive psychology, which seeks to understand the nature of human intelligence and how this works (Anderson, 1985). In more recent times the term ‘coach’ has emerged as a contemporary term used by ‘executive or life coaches’ who are often engaged by business management to improve productivity or equip individuals with the skills that result in success (Savage, 2001). Coaches follow established codes of behaviour that include having realistic and attainable expectations,
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ensuring all players know the rules, earning players' respect, and giving praise as well as being personally committed (Pyke, 1991). The term ‘coach’ as it relates to the CC role discussed throughout this paper, is synonymous with its accepted meaning within the sporting world as one who trains through the processes of instruction and of giving advice (Pyke, 1991). Coaching in relation to clinical education involves ‘the interactive, interpersonal processes through the acquisition of appropriate skills, actions and abilities that form the basis of professional practice’ (Morton-Cooper and Palmer, 1993, p 47, cited in Grealish, 2000 p. 231). The CC role involved adaptation of sporting tenets or principles to the clinical practice milieu and was underpinned by six coaching principles. These principles were to show each student respect; seek to develop their potential; communicate effectively; provide specific feedback; use goal setting to motivate and provide appropriate challenges (Martens, 1997; Crisfield et al., 1996). Coaching sessions were focused on development of student's nursing practice skills affording them opportunity to improve their practice and meet the standards of clinical competency of safe practice. The CC provided support and advice to students and encouraged students to access wider support services provided by the University if necessary. In addition, the CC role included responsibility for contributing to the planning and evaluation of undergraduate course work through direct involvement with curriculum development. The CC tracked all coaching referrals and student progress. The coaching data-base provided the means by which to track the outcomes of the Clinical Coach role over the initial 9 semesters it was implemented. An audit of this data together with a review of literature around coaching for nursing practice development will be presented, analysed and discussed in this paper. Lessons learnt to date about development of clinical practice and the specific coaching strategies that resulted in successful outcomes for referred students will be presented. Patterns and trends that emerged have enabled the CC to make recommendations to the wider School community and of implementing a range of strategies to further support the marginal or ‘at risk’ undergraduate nursing student. Literature review There is extensive literature available in relation to nursing education of students in the clinical environment. Much of this literature relates to aspects of clinical education including the supervision of students, the role of clinical educators and facilitators, university and hospital collaboration, the evaluation of students' clinical competence and the theoryepractice gap. A data-base search was undertaken across several data-bases including CINAHL; Medline and Proquest data-bases using the key words coaching; clinical placement, skills development and nursing students. The literature presented here will only address the nursing literature around coaching when undertaken as a strategic approach for development of nursing practice. Few primary research studies were uncovered and much of the literature around coaching in nursing was simply a descriptive or opinion-based paper. Most literature around the issue of coaching in nursing relates to the staff development and not the students. Research papers that looked at post graduate and/or master's programme students or peer teaching models that called it coaching have not been included as the CC role presented in this paper was only for undergraduate nursing students. Several articles reviewed, discuss the merits of coaching as an effective strategy for nurse managers to adapt in order to promote learning and to develop self-awareness amongst nursing staff. As far back as the 1990s Pethigal (1991), Haas (1992), Cole (1994) and Whyte (1997) all determined that coaching principles could be
used to support staff development. Haas (1992) provided a coaching framework and presented the techniques and central principles essential to coaching that involved six phases including observing and auditing, analysis, discussion, channelling, delegating and feedback (Haas, 1992, p 56). According to Cole (1994), coaches needed to possess certain skills that included being credible, patient, supportive, flexible and respectful of the learner. Cole (1994) concluded that the coach required keen observation and a high level of interpersonal skills, an understanding of the principles that feedback should be descriptive and not judgemental and knowledge of the principles of adult learning and ability to apply them. Whyte (1997) concluded coaching methods could be used to help individuals to develop the ability to learn, as opposed to having to teach them, in a way that fostered their ability to maximise their own performance. Hallett's (1997) phenomenological interpretive study examined the relevance of Schon's (1987) theories of coaching to nursing education in the UK. Hallett's study focussed on aspects of Schon's theories that could be utilised by community based nurses who undertook the supervision of college based nursing students. Schon's (1987) theories consist of the application of three types of coaching within the studentecoach relationship. These included “Joint Experimentation” in which the student and coach work, discuss and debate together, “Follow Me” a process by which the student learns to imitate the coach and “Hall of Mirrors” in which insight of practice facilitates learning (Schon, 1987). Hallett (1997) presented learning as a sequence of events composed of seven stages and concluded that knowledge and understanding grew out of practice for both students and supervisors. These seven stages included encountering reality, having a go, gaining confidence, thinking through and understanding, developing ideas, being independent and being assessed (Hallett, 1997, p106). Hallett's (1997) work was an exceptional study that provided an educational pedagogy that enhanced outcomes for nursing students undertaking placement using a coaching philosophy developed by Schon (1987) that she showed had real relevance in the clinical education of nursing students. Kowalski and Casper (2007) set out to gain a better understanding of the potential of coaching in nursing by drawing on the extensive study of clinical nursing practice in the clinical environment undertaken by Benner. Benner's work, published in 1984, was the culmination of descriptive research of nursing practice that applied the Dreyfus model of five distinctive levels of skill acquisition to unpack the notion of expertise in nursing practice. Benner (1984) was instrumental in highlighting how nurses develop in their nursing practice and how that development is paraleled with their gaining of ongoing experience. Such a framework provides a sound pedagogical base for understanding how skills acquisition, the primary aim of coaching, develops. Kowalski and Casper (2007) concluded that in order to be effective, the coach must have the experience of practice, that is be advanced or expert in their own practice, so as to best provide opportunity to others and assist staff in developing ability to integrate theoretical knowledge and so enhance and develop their clinical practice. Nursing literature uses several terms to describe specific support that can be afforded students including coaching, mentoring and facilitation to name a few. Sherman (2006) examined the impact of coaching across generations as in an unprecedented situation, four generations now make up the current nursing workforce. Sherman (2006) evaluated how the generations differ in their attitudes and behaviours towards coaching and mentoring, terms incorrectly used interchangeably throughout nursing literature, and showed that these terms mean different things to the different generations. In making a distinction for this paper, between coaching and mentoring, coaching is task oriented with a focus on
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M.F. Kelton / Nurse Education in Practice xxx (2014) 1e5
concrete issues, it is short-term and is performance driven whilst mentoring is relationship-oriented and is long-term (Fielden et al., 2009). Specific literature exploring and discussing nursing literature around coaching undertaken as a strategic approach for development of nursing practice has been presented. Very little literature undertaking research around the Clinical Coaching of nursing students was uncovered. Hallett's (1997) phenomenological work was primary research work that evaluated the application and use of coaching principles and strategies to develop and improve nursing students' clinical practice. Much of the grey literature identified supports the benefits and nuances of using a coaching model including various coaching strategies for the development of clinical staff. No literature was uncovered that explored the outcomes of a Clinical Coach as a targeted academic role to purposively improve and develop the marginal or ‘at risk’ undergraduate nursing student's clinical practice. The uniqueness of this academic role warranted evaluation of what it could achieve. Results from the audited data collected during the initial 9 semesters following the appointment of the CC in one School of Nursing and Midwifery are presented in the following section. Results/methods Auditing is as an accepted method for conducting analysis of data and is useful for examining and determining through objective evidence the effectiveness of implementation of a particular planned activity for a stated purpose (Closs and Cheater, 1996). The data-base tracked measurable evidence and outcomes for all students referred to the CC with identified practice deficits. Specifically the data tracked included the students' year level; reason(s) or issues prompting the referral; outcomes following coaching sessions and English Second Language (ESL) status. Confidentiality was maintained at all times and all data entered depersonalised so as to ensure students' identity remained protected in keeping with ethical responsibilities of the CC. A total of 188 students was referred for assessment by the Clinical Coach comprising 121 third years, 64 second years and 3 first years. Table 1 is included as a summary of the collated data. Clinical Coaching achieved good outcomes with 156/188 students going on to successfully complete clinical placement and to pass their program. Following the initial coaching assessment 9 students were deemed by the Clinical Coach as having a satisfactory, safe level of practice and so were not accepted for coaching and their academic coordinators informed. Coaching was not punitive as the performer wishing to engage is considered essential to achieving successful outcomes (Crisfield et al., 1996). When 2 students did not wish to undertake coaching they were not forced to and were
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followed up instead by their academic coordinator. Some students elected to withdraw themselves from the program for various reasons mostly relating to personal situations impacting on their study or ability to set aside the time required to attend clinical placement. Academic coordinators withdrew 3 students from their clinical placement when it became obvious these students could not meet academic requirements of the topic. Table 1 summarises collected data following implementation of the CC role over 9 semesters. Poor professional communication skills, in fact, was the most common reason identified by supervising clinical staff that had prompted referral of the student for assessment by the CC. ESL was found to be a significant factor in the number of referrals around communication with 151/188 students referred during the period presented having an ESL background. This statistic included both international and domestic residents with an ESL background as their issue was with language difficulties, not residency status. Even following extensive coaching, one student remained unsafe and was deemed a risk to patients and staff due to her very poor communication skills compounded by her ESL background. The student was counselled and advised to undertake remedial English language classes. She was removed from clinical placement and recorded as a fail in the coaching data-base. Clinical Coaching involved a five-step systematic approach that included comprehensive assessment; demonstration of skills; supervision of one to one remedial practice sessions; provision of feedback and finally debriefing. Case based scenarios and quizzes reflecting the particular clinical environment where the student had been undertaking placement were also used during this initial coaching assessment. Students were set a range of activities that assessed their psychomotor skills, their ability to plan and prioritise nursing care and the effectiveness of their communication skills. The Bondy Scale (see Appendix 1) and a Level of Competence Tool (see Fig. 1) used during this initial assessment enabled the CC to determine the need for coaching identify student's specific practice deficits. Students who were assessed in the assessment session as a 1 or 2 using the Bondy Scale (see Appendix 1) and as either consciously competent (stage 3) or unconsciously competent (stage 4) against the competency gradient tool above did not require coaching. These are the students who following coaching assessment were not accepted for coaching (see Table 1) and their academic coordinators subsequently informed. The consciously incompetent student as identified by Lake and Hamdorf (2004) and Peyton (1998) is aware of their practice deficits and was found to be the group of students who most actively engaged in the coaching process. The unconsciously incompetent student, however, were the most difficult to coach. Unconsciously incompetent students were found by the CC
Table 1 Clinical Coach data. Statistics: Semesters 1e9
Total student referrals Third year Second year First year English second language Outcome of coaching Passed clinical placement Student withdrew self from program Withdrawn by other Failed Not accepted for coaching Total
S1
S2
S3
S4
S5
S6
S7
S8
S9
Totals
12 8 4 0 10
20 12 8 0 19
11 7 4 0 9
26 24 2 0 25
24 12 12 0 21
26 16 10 0 20
13 7 6 0 10
31 23 8 0 22
25 12 10 3 15
188 121 64 3 151
8 4
17 2
10 1
22 2
22 0
18 5
12 1
25 2
22 2
156 19
0 0 0 12
0 0 1 20
0 0 0 11
1 0 1 26
0 1 1 24
1 0 2 26
0 0 0 13
1 0 3 31
0 0 1 25
3 1 9 188
Stage1. Unconsciously Incompetent
Student does not realize what they don’t know
Stage 2. Consciously Incompetent
Student realises they don’t know Student realises they know and can do with great thought
Stage3. Consciously Competent Stage 4. Unconsciously Competent
Student does without thought
(Adapted from Lake and Hamdorf, 2004; Peyton, 1998)
Fig. 1. Level of competence tool.
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to lack insight into their poor practice and often failed to recognise their own practice limitations even acting outside their scope of practice. With the potential for these students to cause harm to patients the CC recommended to academic coordinators that the action plan was to suspend these students from clinical placement until they were able to demonstrate a safe level of clinical practice in the simulated laboratory environment. Communication deficits and other reasons that prompted referral to the coach by clinical facilitators warrant further discussion. These issues together with discussion and exploration of the specific coaching strategies applied to manage and develop the marginal performer or ‘at risk’ students' nursing practice will be presented in the Discussion section. Discussion Students who are not proficient in their practice tend to be slow and uncoordinated with skills and lack confidence in their clinical practice (Bondy, 1983). These students take a long time to get through the tasks and then have little or no time for reflection on the wider implications of their nursing practice. Such uncoordinated care often requires frequent prompting from staff and when coupled with a lack of proficiency with technical clinical skills results in unsatisfactory practice. Characteristics of the marginal performer as identified by Bogo and Vayda (1998) and further developed by Cooper et al. (2003) include the inability to link theory and practice; of being task oriented, requiring constant direction and prompting and of lacking ability to reflect on practice regarded as critical skills for practice development (Ervin, 2005; Whyte, 1997). Poor practice by marginal performers gets noticed by supervising clinical staff and when reported to the Clinical Facilitator whose role it is to ensure our nursing students meet both university and professional expectations during clinical placement prompted referral to the CC. Skills development to a proficiency level requires more than just performing of the actual task as it requires integration of knowledge, skill and communication (Lake and Hamdorf, 2004). Coaching was undertaken in a purpose-built skills laboratory using standardised patients and high and medium fidelity manikins. Skills sessions were contextualised with the students providing comprehensive nursing care for patients in a simulated environment designed to reflect their relevant clinical placement practice setting. The reasons students had not mastered specific psychomotor skills varied. Some students had not been taught the correct method to begin with and others had been afforded limited opportunity to practice the more complex skills. Many students had been influenced by poor practice they had observed or been taught during their clinical experience placements, whilst in some instances the students simply lacked the fine motor skill required to perform psychomotor skills. Poor communication, the most common reason for referral to the coach, has far-reaching implications for the student themselves, the clinical staff who provide supervision and for the patients to whom that student is responsible for providing nursing care. Many of the students referred for coaching were involved in critical incident or near-miss situations including medication errors. Coaching sessions sought to correct students' communication deficits by incorporating activities including interpreting medication charts accurately and how to seek clarification from supervising clinical staff if unsure. Evidence has shown that cultural and linguistic diversity (CALD) students require higher levels of support when undertaking clinical placements to ensure they perform at the expected level (Harvey et al., 2013). The high numbers of ESL referrals to the CC became instrumental in the wider school community seeking out additional practice development strategies to
support CALD students. The result was the development of a Clinical Communication Programme (CCP) a tool that assisted students to understand and apply professional clinical language and jargon common to the clinical environment and to be able to document accurately and to be computer literate. Other practice deficits prompting referral included an inability to provide fundamental or basic nursing care; failing to implement effective time-management skills or lacking ability to plan and prioritise nursing care. Following coaching sessions that involved demonstration, instruction and guidance, many of the students not only returned to complete placement but also went on to get excellent clinical reports. What became evident was that the earlier in the placement the student was referred for coaching the better the end outcome. Supervising clinical staff noticed when practice improved, in some instances it was a vast improvement, and this then facilitated their willingness to allow the student to engage more fully in patient care. This had a flow on effect as it resulting in the student's self-confidence growing which in turn further enhanced their clinical practice capabilities. Confidence and motivation instilled through coaching processes results in improved nursing practice (Grealish, 2000). The coaching process was underpinned by coaching approaches earlier identified by Pethigal (1991), Haas (1992) and Cole (1994) especially the use of assessment, observation, analysis and discussion. Feedback was used by the coach following assessment and observation in order to facilitate analysis and discussion. Specific feedback aimed at developing reflective practice skills was a critical strategy utilised by the CC to support student's ability to identify their practice deficits. Specific feedback is feedback that is directed at behaviour that is changeable using an informative, positive, corrective process that provides precise detail about what the student should do in order to solve or correct a problem (Martens, 1997). According to Ende (1983), without feedback mistakes go uncorrected and good performance is not reinforced. A determination of the students' level of maturity was required when giving feedback so that as Whyte (1997) had discussed the recipient's ability to identify their own practice deficits was fostered and helped them assume responsibility for their own learning. Coaching is purposeful and is underpinned by educational philosophies that by design seek to ensure learning occurs. Debriefing, with its military origins, is the term used for a description of a situation that moves beyond talking to the process through analysis and development of strategies for future application in a similar situation (Fanning and Gaba, 2007). Debriefing was used by the CC to generate discussion and analysis that creates insight and awareness of practice that as Hallett (1997) showed facilitates learning. Third years, in particular, need to have moved beyond the stages of ‘noticing’ or ‘making sense’ of clinical placement to a level where they are beginning to ‘make meaning’ of their experience (Martin and Fleming, 2010). Debriefing provided a way for the CC to encourage students to articulate clinical rationales for the nursing practice they implemented. As students became more confident in their ability to provide rationales for practice their ability to selfreflect also improved.
Limitations This study is limited in that it is based on only 9 semesters of data collection. It would be remiss, not to acknowledge that students would have weighed up the risk of failing their clinical component of topics when making their decision to attend. A longitudinal study and evaluation of qualitative data as distinct from a simple audit would provide a more effective way to continue to gather evidence of the impact of the role of Clinical Coach.
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Conclusions/recommendations Clinical Coaching begins with referral of a student whose clinical nursing practice has raised concerns amongst the supervising clinical staff. Coaching involves assessment of the students' competence and performance. Coaching strategies purposively designed to build confidence, develop understanding and increase ability to demonstrate the core attributes of practice are applied. The purpose of this paper was to present the outcomes achieved through these coaching strategies when a Clinical Coaching role was implemented to support and develop nursing practice for the marginal performer or ‘at risk’ student. A literature review around coaching in nursing examined its application when seeking to enhance performance. Data collected over nine semesters of the Clinical Coach role was presented and showed that following coaching sessions high numbers of the students went on to successfully complete their clinical placement. Communication inadequacies steeped in ESL issues was the most common reason for referral. Opportunity exists for further research into adoption of this model of Clinical Coaching by other Schools of Nursing and Midwifery. Further research to evaluate the application of specific coaching strategies and explore coaching practices that may offer a transferable, adaptable and flexible approach for other health professions who require undergraduate students to complete clinical placements is warranted.
Appendix 1. The Bondy Scale
1 Independent & excellent performance Demonstrates an excellent understanding of knowledge underpinning practice. Very coordinated, proficient and confident in technical clinical skills. Professional and caring at all times. Excellent effective interpersonal communication skills with patients and staff. Very good ability to synthesise theory and practice with minimal prompts. Very well developed clinical reasoning skills. The student deserving of a score of 1 will require minimal prompts for thinking or actions from staff. 2 Infrequently assisted & good performance Demonstrates a sound understanding of knowledge underpinning practice. Coordinated, proficient and confident in technical skills. Professional and caring at all times. Good effective interpersonal communication skills with patients and staff. Good ability to synthesise theory and practice with infrequent prompts. Good clinical reasoning skills. The student deserving of a score of 2 will require some prompts for thinking or actions from staff. 3 Assisted & satisfactory performance Demonstrates a satisfactory understanding of knowledge underpinning practice. Coordinated, proficient and confident in most technical skills. Will usually consult appropriate resources prior to asking for assistance. Professional and caring at all times. Appropriate interpersonal communication skills at all times. Satisfactory ability to synthesise theory and practice requiring prompts at times. Satisfactory clinical reasoning skills. The student deserving of a score of 3 requires and seeks prompts for thinking or actions from staff. 4 Dependent & unsatisfactory Deficit in knowledge underpinning practice. Requires frequent prompting to elicit knowledge. Uncoordinated, unconfident and lacks proficiency in basic technical skills. Professional conduct and caring not consistently demonstrated. Frequently demonstrates ineffective interpersonal communication skills. Inability to synthesise theory and practice even with frequent prompting and support.
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(continued ) The student deserving of a score of 4 will require frequent verbal and physical direction from staff. Adapted from Bondy (1983) Journal of Nursing Education. 22(9); University of South Australia (1999) Bachelor of Nursing Clinical Assessment Form; Flinders Medical Centre Performance Review Graduate Nurse.
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