TEACHING FOR PRACTICE
By Linda Koharchik, DNP, MSN, RN, CNE, and Karen Jakub, PhD, RN
Starting a Job as Adjunct Clinical Instructor Site details and school expectations vary—preparation is crucial.
This article is the second in a new quarterly series on the roles of adjunct clinical faculty and preceptors, who teach nursing students to apply knowledge in clinical settings. Topics will include the preparation of clinical instructors and preceptors for these roles, the student evaluation process, and overcoming challenges that can come with teaching in the clinical field and with adjunct teaching.
o you’ve accepted the contract for your first part-time clinical teaching assignment and you’re wondering where to start in preparing for this new role. Perhaps you’ve been working in an administrative role, away from direct caregiving. Maybe you’ve been active in bedside nursing but have no formal preparation in clinical teaching. If you take the time to prepare for your teaching assignment, you can confidently lead your students through a meaningful clinical experience. This article will describe the groundwork needed to be a successful clinical educator. (For a detailed description of this position, see the previous article in this series, “Delineating the Role of the Part-Time Clinical Nurse Instructor,” May.)
In most schools of nursing, an orientation program is offered for adjunct clinical faculty. Attendance may be optional, but for the first-time clinical instructor, it can be invaluable. Although orientation quality can vary, ideally the orientation will include information about site and school expectations for the clinical instructor as well as for the nursing students you will teach. Practical details. The orientation may present essential information about school policies and procedures, the clinical calendar, the associated learning lab schedule, student evaluation practices, and coursespecific details—as well as about how you will be evaluated. The orientation session may also include the schedule for payments to clinical faculty and an explanation of the procedure for reimbursement of parking at clinical sites. Learning the curriculum. In a survey conducted by Davidson and Rourke, clinical nurse instructors identified orientation to the curriculum as essential preparation, noting as well the importance of a close [email protected]
correlation between students’ clinical experiences and the content of their concurrent courses.1 Clinical faculty need to gain an awareness of the current course theory, previous coursework, and course objectives so they can appropriately assign patients to students. Adjunct clinical instructors will also be informed of their role in the nursing lab if that is part of the clinical teaching. Getting to know the faculty. The orientation session is also an excellent opportunity to connect with other adjunct faculty, especially those who teach at the same course level or in the same clinical facility. More seasoned clinical faculty can serve as mentors and promote professional growth in newer faculty. Take advantage of this time to exchange contact information, as these peers can be a great source of support in answering questions you may have about a specific site. Unit-specific information. Sometimes a site will also offer an orientation for clinical instructors. Each unit has a unique routine and may have specific schedules for tasks such as taking vital signs. Hutchinson and colleagues describe a 16-hour orientation model developed by a hospital’s student service team and note that such a program improves instructor familiarity with unit-specific information.2 In this model, the clinical instructor is paired with a staff member and given a detailed written self-learning guide about the unit that addresses patient demographics and staff ratios, how to access medications and supplies, and current process improvement projects in which the unit is involved. The formal orientation program includes a meeting with a unit representative, and offers instructors a list for students of resources for observational experiences within the hospital. Taking the initiative. If the clinical site doesn’t offer an orientation program, the adjunct clinical faculty must pursue an orientation to the assigned clinical unit. Making arrangements with the unit manager to AJN ▼ August 2014
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Clinical instructor Betsy Moorhouse (second from right) reviews the contents of a pediatric code cart with her nursing students at Miles Memorial Hospital in Damariscotta, Maine. Photo © Getty Images.
shadow a nurse on the unit for a day or two prior to starting the term can be helpful in reaffirming basic skills if you’ve been away from the bedside for a while. This is the perfect time to address unit-specific concerns not typically covered in orientation. • Observe change-of-shift report. Is it given as a taped recording, at the bedside, or face-to-face in a conference room? • Note the location of staff assignment sheets and ask where to post student assignments. • Clarify whether you and your students will leave the unit together for lunch or go in shifts. • Become familiar with the unit facilities, clean and dirty utility rooms, locker rooms for students, the conference room, and staff restrooms. (Sometimes numeric codes must be used to access these areas, so be sure to take notes. It’s easy to forget this information from one week to the next.) Clarify if any areas, such as the family waiting room, are off-limits to students. Get to know the location of equipment such as blood pressure monitors, thermometers, and supplies. • Take this opportunity to become oriented to the unit’s medication administration and charting procedures. If the hospital uses computerized charting and electronic scanning for medication 58
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administration, you will need to have passwords. • Familiarize yourself with the computer system so you can access hospital policies and procedures, drug information, and patient teaching materials. • Get to know the staff, and seek out the unit manager. • Clarify unit expectations for yourself and the students: Will staff nurses participate in teaching students? Springer and colleagues describe an innovative model called the “dedicated education unit,” to which a nursing school’s students are assigned.3 In this model, hospital nurses play an active role in student clinical education and work one-on-one with students. Variations of the model exist, and the role of the clinical instructor can vary. Staff nurses may not be actively engaged with students in activities such as medication administration, and the number of students per day who administer medications with the clinical instructor may be limited. Selecting student assignments. You may be expected to come to the hospital a day in advance to select students’ patient assignments. This is not always a requirement, and with the continued shortening of patients’ length of stay, it may be unproductive. A more practical approach is to arrive earlier than the ajnonline.com
students on the clinical day to consult with the charge nurse about potential student assignments. Bearing in mind the abilities of the students, try to select patients whose conditions may prove relevant to the content of current coursework. (If you assign your students too many complex patients, you may be setting yourself up for an overwhelming day. Hewitt and colleagues advise keeping a logbook of student assignments and the types of patients they have cared for so you can make assignments fairly.4) Determine which students will be administering medications and review the administration record for medications that are unfamiliar to you. If your clinical facility uses electronic records, you may be able to print out the nurse handoff report for your students. In fact, printing a handoff report for yourself as well helps you to be organized and aware of each patient’s needs. Once you have made the students’ assignments, inform the nursing staff of the assignments, what the expectations for the students will be, and which students will be administering medications.
THE FIRST DAY
You have prepared and oriented yourself to the unit. You may have had the opportunity to meet your students before the first day at the hospital, or this may be your first meeting. Providing detailed instructions and communicating with your students will promote a smooth introduction to their new clinical setting.
unfamiliar and discomforting, particularly for those in their first clinical experience.5 Even students who have been in the clinical setting in previous semesters may feel apprehensive—they may be worried about having a new clinical instructor, for example. Establishing attendance policy. The first hour or two of this initial day should be spent reviewing your clinical expectations with the students. Find a private conference room or similar space in which students can ask questions and speak freely without fear of being overheard by patients or staff. Some important items to review are the clinical attendance policy and how to call in sick. Some nursing units may request that students contact not only the instructor but also the charge nurse on the unit. Give the students an acceptable time frame in which to call. For example, you may request that they call between the hours of 5 am and 6:30 am, which will give you ample time to adjust the students’ patient assignments. Some nursing programs require clinical makeup time for unexcused absences. Be sure to review those policies with your students as well. Setting expectations. Let your students know what type of clinical assignments they will have. Will they be caring for more than one patient? How will their assignments progress throughout the semester? Share what you have gleaned from your orientation on the unit. Include areas and locations on the unit that students may use and access codes for utility
The first hour or two of the initial clinical day should be spent reviewing your clinical expectations with the students. Getting around. Designate when and where to meet on this first day. Do not assume your students know how to get to the health care facility or where to park. Transportation and parking can be stressors for students who are new to the area or unfamiliar with the hospital. Many hospitals have designated areas for student parking, so providing a map for your students may be helpful. Suggest they allow ample time for transportation to accommodate traffic, especially if the facility is within a large multihospital system or urban area. Where to meet. Designate a specific place to meet in the health care facility. It may be helpful to meet your students at a public location such as the cafeteria or the lobby before going to your assigned nursing unit. This can help to decrease students’ anxieties: many nursing students report that the health care environment can be [email protected]
rooms or medication rooms, if appropriate. Explain the routines and flow of the unit and the nursing staff’s expectations of the students. If the students are on a specialized unit, you may want to suggest they read specific articles on evidence-based practice so they may be better prepared for patient care. For example, if you are assigned to a neurologic unit, readings might be chosen to help students refresh their knowledge of neurologic assessment, pathology, stroke scales, and neurology-specific medications. Students may have questions about whether they can go with their patients to other departments or spend a clinical day observing in a specialized area such as the operating room or cardiac catheterization lab. If a student is to accompany a patient for a procedure or test, you should make sure that student observation is permissible and that the staff is aware a AJN ▼ August 2014
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student will be present. In addition, if you would like your students to rotate through specific specialty areas, you should contact the managers of those departments to make the necessary arrangements. Providing a clinical calendar will be helpful for students when clinical days are affected by clinical observations, holidays, or other school-related activities, such as skills labs or simulation experiences. The evaluation process. Talk with your students about their evaluation. Nursing students can be very anxious about being observed and evaluated by their clinical instructor. To allay their fears associated with performance, explain what you plan to observe and how students will be evaluated. If you are planning to keep anecdotal notes on your students, explain what you will be doing and how you plan to use these in the evaluation process. Remember that students are not yet experts in the field of nursing. Explain that you will provide support but expect adequate preparation, and that you will compliment them on their accomplishments as well as guide them through times when they lack the skills or knowledge to handle a situation independently. Professionalism. Stress to your students the importance of professionalism, of understanding that the manner in which they present themselves will be seen as a reflection of the school and of their overall respect for the profession. Be consistent with the school’s policy on dress and conduct. Professional conduct is beneficial for enculturation into the hospital setting. Your students are entering into a community of practice that has differing social structures and intertwined networks—acceptance as a member of this culture can be empowering for students. Responsibility. This may also be the time to start a conversation about professional responsibility. Students may feel vulnerable and personally accountable for the added responsibilities associated with patient care.6 They may also have questions regarding their patients’ social status, race, ethnicity, or sexual orientation. In addition, they may voice concerns about caring for a patient with a transmittable disease or one who is having a procedure that goes against their moral, ethical, or religious beliefs. Talk with your students about the nurse’s responsibility to care for each patient despite personal preferences. This topic can be complex and should be discussed further, perhaps in a postconference setting in which current literature on the topic may be presented. Familiarization with the unit. For the remainder of the first day, have the students engage in activities that will help them become familiar with the environment and the unit’s routines. Start with a tour of the hospital so they can see other patient care areas, such as radiology, specialization labs, and physical 60
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therapy. Point out key areas where patients’ families may congregate, such as cafés, special waiting rooms or family rooms, and the cafeteria. Lastly, tour the unit where your students will be caring for patients. To familiarize students with the nursing unit, some clinical instructors like to engage the students in a scavenger hunt. Although this type of activity can be helpful, it may be a source of stress to any students who feel awkward or embarrassed being observed by nurses, physicians, and staff. (Moridi and colleagues found that a high level of stress among nursing students is related to experiences they perceive to be humiliating.7) With any such activity, be sure to observe your students and others and terminate the activity if it is causing undue stress. Pairing students with unit nurses. Lastly, if possible, pair your students with nurses working on the unit. This provides individualized orientation and begins the fostering relationship between the students and nurses. Always make these arrangements at the beginning of the day, so the unit nurses can expect to spend time with the students. Before pairing up the students, check with each nurse to make sure they can still accommodate your request. They may not be able to work with a student because of their patients’ acuity and subsequent demands of care. Providing a safe and productive clinical experience for your students begins with careful planning and a solid faculty orientation. Extending this orientation to the students will in turn help to decrease their anxieties and facilitate learning. ▼ Linda Koharchik is a clinical assistant professor and director of adjunct faculty and clinical affairs, and Karen Jakub is an assistant professor, both at Duquesne University School of Nursing, Pittsburgh, PA. Contact author: Linda Koharchik, [email protected]
duq.edu. The authors have disclosed no potential conflicts of interest, financial or otherwise.
REFERENCES 1. Davidson KM, Rourke L. Surveying the orientation learning needs of clinical nursing instructors. Int J Nurs Educ Scholarsh 2012;9(1):Article 3. 2. Hutchinson PJ, et al. “Know worries!” a clinical faculty orientation model. Nurse Educ 2011;36(2):59-61. 3. Springer PJ, et al. The Idaho dedicated education unit model: cost-effective, high-quality education. Nurse Educ 2012;37(6):262-7. 4. Hewitt P, Lewallen LP. Ready, set, teach! How to transform the clinical nurse expert into the part-time clinical nurse instructor. J Contin Educ Nurs 2010;41(9):403-7. 5. Melincavage SM. Student nurses’ experiences of anxiety in the clinical setting. Nurse Educ Today 2011;31(8):785-9. 6. Keeling J, Templeman J. An exploratory study: student nurses’ perceptions of professionalism. Nurse Educ Pract 2013;13(1):18-22. 7. Moridi G, et al. Clinical training stress-inducing factors from the students’ viewpoint: a questionnaire-based study. Nurse Educ Pract 2014;14(2):160-3. ajnonline.com