CGFNS International

Guidelines for Clinical Teaching Guidelines for Clinical Teaching

And Evaluation of Students
Amman, Jordan
May 13-14, 2009
Barbara L. Nichols, DHL, MS, RN, FAAN
Jordanian Nursing Council
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INTRODUCTION

The Commission on Graduates of Foreign Nursing Schools (CGFNS
International) is pleased to present this workshop on test development, which
includes clinical teaching and evaluation. These guidelines outline fundamental
principles for planning clinical learning and the use of varied clinical evaluation
strategies.



SECTION 1 Discusses Philosophy of Clinical Teaching and Evaluation

SECTION 2 Identifies Essential Elements of Clinical Teaching

SECTION 3 -- Describes Models of Clinical Teaching

SECTION 4 Discusses the Process of Clinical Evaluation
























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SECTION ONE PHILOSOPHY OF CLINICAL TEACHING AND EVALUATION


This section discusses a philosophy of clinical teaching and evaluation.

A philosophy of clinical teaching includes beliefs about the values of clinical
education, the roles and relationships with teachers and learners. It represents
shared beliefs that serve as a guide to action and provides structure and
coherence for curriculum development.

The philosophy includes beliefs about the role of the teacher, which is to provide
opportunities and activities that facilitate learning. In the clinical setting, the
student is not a nurse, but a learner. The central focus is on learning, not doing.
Historically, clinical learning activities in nursing education have been confused
with caring for patients. The teacher provides competent guidance. The goal of
clinical learning is for the teacher to select assignments that contribute to student
learning, and to produce students who demonstrate knowledge and skills,
common to beginning nursing practice. (Gaberson & Oermann, 2007)


The Process of Clinical Evaluation

The process of clinical evaluation includes the determination of set criteria, which
identify the objectives and competencies to be met in the clinical environment.
By defining the terms ahead of time, there are objective measures of
performance on which to base the evaluation by which all students activities are
evaluated to the same standard. The teacher plans the clinical learning activities
to achieve these objectives.

In short, the role of the teacher in the clinical setting is to be a facilitator of
learning, providing competent guidance to students who experience the learning.

Differences in philosophy can profoundly effect decisions about teaching or
evaluation methods, setting, outcome, and role behavior, which are grounded in
the teachers philosophical perspective. The core values of the teachers
philosophy of clinical teaching serve as a basis for improvement of clinical
teaching and evaluation.









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SECTION TWO ESSENTIAL ELEMENTS OF CLINICAL TEACHING


This section describes clinical learning activities.

Clinical teaching involves clinical learning activities that enable students to
transfer knowledge learned in the classroom to patient care. Outcomes of
clinical teaching include the acquisition of knowledge, skills, and attitudes
through experiences in the clinical setting. The teacher must plan activities for
the acquisition of 1) Knowledge, which includes problem solving, critical
thinking, and decision making; 2) Skills, which includes psychomotor skills,
interpersonal skills, and organizational skills; and, 3) Attitudes, which includes
affective outcomes, such as beliefs, values, attitudes, and respect.

Clinical Activities for Knowledge Building:

1. Clinical Problem Solving. Clinical learning activities are assigned that
provide rich opportunities to practice problem solving related to patients and
their health to be solved.

2. Critical Thinking. Critical thinking involves collecting appropriate data,
analyzing information, and determining a course of action. Again,
emphasizing the importance of this in the clinical arena.

3. Decision Making. Decision making requires that nurses make decisions
about the course of action to take regarding patient care, and assignments
focus on actions to be taken.

Clinical Activities for Building Skills:

4. Psychomotor Skills. Psychomotor skills are purposeful, complex
movements, which include the ability to perform proficiently under varying
conditions within appropriate time limits. Learners need sufficient
opportunity in the clinical environment to master psychomotor skills.

5. Interpersonal Skills. Interpersonal skills are used to assess client needs, to
evaluate the outcomes of care, and to record and disseminate information.
Interpersonal skills include communication, therapeutic use of self, and
teaching patients and others.

6. Organizational Skills. Organizational skills require nurses to set priorities,
manage conflicting expectations, and sequence their work to perform
efficiently. Organizational skills also require delegation skills, which means
the nurse needs to know what to delegate, to whom, and under what
circumstances.

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Clinical Activities for Attitude Building:

7. Attitude Building. Clinical activities for attitude building include focusing
on client experiences that represent humanistic and ethical dimensions of
nursing. Nurses are expected to hold and act on certain values with regard
to patient care, and to use the processes of moral reasoning, values
clarification, and values inquiry (American Nurses Association Code of
Ethics for Nurses, 2001).



Summary
Thus, the clinical environment affords the opportunity to provide successful
outcomes based on knowledge, skills, and attitudes acquired through clinical
teaching and learning. The outcomes of clinical teaching and learning require
that the teacher
1. Assess the learning needs of students;
2. Plan clinical learning activities;
3. Guide learners in clinical practice; and
4. Evaluate clinical learning and performance.

Clinical learning activities focus on the development and application of
knowledge that cannot be acquired solely in the classroom (Derickson & Caputi,
2004; Yoder-Wise, 2003).




















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SECTION THREE MODELS OF CLINICAL TEACHING


There is no one model of clinical teaching. Several factors need to be
considered, such as the educational philosophy of your nursing program, the
philosophy of the faculty about teaching, intended outcomes of the clinical
experience, the level of the nursing student, the nature of the clinical setting, the
availability of preceptors and expert nurses, and the willingness of the clinical
agency to be a partner.

Three models, however, dominate, and they will be briefly explained, the
traditional model, the preceptor model and the partnership model.

Traditional Model: In the traditional model of clinical teaching, the
educator/faculty member provides the instruction in the clinical area. The faculty
member selects the clinical activities in patient care that meet the students
needs and are consistent with course goals and objectives. A benefit of this
model is the opportunity to assist students in using the concepts and theories
learned in class and other learning activities in patient care. A major
disadvantage of this approach can be the large number of students for whom
faculty members may be responsible; not being accessible to students when
needed because of demands of other students; and the time commitment of
providing the on-sight time required for clinical instruction.

Preceptor Model: This model involves sharing clinical teaching responsibilities
between nursing program faculty and expert clinicians from the practice setting.
However, the faculty member is responsible for clinical and teaching outcomes.
The faculty member from the school of nursing serves as the course coordinator,
provides liaison between the school and clinical setting, and serves as a
resource person for the preceptor. The preceptor is an expert nurse in the clinical
setting, and may be a staff nurse or other nurse employed by the agency who
has the knowledge and skills that meet the teaching goals and objectives.

The preceptor model is commonly used in upper level, clinical courses. The
major disadvantage of the preceptor model is the lack of flexibility and re-
assigning students to other preceptors, if needed.

Partnership Model: There are various types of partnership models in nursing
education. They vary with the academic institution involved, but generally, are a
collaborative relationship between the school of nursing and a clinical agency, or
among varied agencies in the community.

In selecting a clinical teaching model, it is good to remember that no one model
meets the needs of every nursing program, and in fact, the teacher may use
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models in combination. The teacher, in selecting a model, should consider the
following factors:

Educational philosophy of the nursing program;

Goals and intended outcomes of the clinical course and activities;

Level of the nursing student;

Type of clinical setting;

Availability of preceptors, expert nurses and other people in the practice
setting to provide clinical instruction; and

Willingness of clinical personnel and partners to participate in teaching
students in their facilities.






























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SECTION FOUR THE PROCESS OF CLINICAL EVALUATION

The process of clinical evaluation requires that the teacher identify objectives or
competencies for clinical experience. These should be set criteria that identify
objectives/competencies to be met. The teacher plans clinical learning activities
to achieve the objectives. The individual student assignment is based on
learning needs, as assessed by the teacher and student.

In clinical evaluation the teacher is assessing the extent of the students learning
and performance in clinical practice. The focus is on the process, which confirms
that the student has developed the basic competencies.

There are a number of tools and methods that can be used to collect data for
student evaluation. It is recommended that the teacher use several approaches
and not rely on any one method. Tools can be criterion-based or normative.

Criterion-based tools are pre-set definitions against which the student is
evaluated, e.g. a procedural check-list and rating scales are examples of
criterion-based tools.

Normative reference evaluations compare a students clinical performance
against that of other students within the group.

Portfolios are an evaluation tool that demonstrates the students best work
across the clinical term. It is a self-collected sample of projects to show student
learning and growth.

Student Journals also can be used, which provide insight into a students values
and beliefs, and allow for reflection on strengths and weaknesses.

Anecdotal Notes are another common method of evaluation. Anecdotal Notes
present a narrative describing observation of the learners conduct that the
faculty provides. The note is brief and factually describes student behavior. It
does not include faculty judgment.

Other evaluation tools are simulations, written assignments, conferences, group
projects, and self-evaluation. The key here is that multiple approaches should be
used.


Summative and Formative Evaluation in the Clinical Area

Formative evaluation is frequent, on-going comments to the student about
progress and meeting objectives and competencies. It is intended to identify
learning needs, and its purpose is to provide immediate feedback related to the
observed actions, sighting both the adherence to and deviation from practice
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standards. Recommendations for improvement and a timeframe for
improvement are identified. The instructor should keep documentation of formal
and informal formative evaluation conferences, as well as student progress in
meeting expected practice requirements.

Summative evaluation communicates the students success at meeting the
stated objectives and competencies of the course. It occurs at the end of the
instructional period. In addition to the described evaluation tools, summative
evaluation may take into consideration other areas of the students work, e.g.
perspective of staff, patient comments, and professional behavior and
appearance. The clinical grade is the end result of the summative evaluation.


Grading Systems

Grading systems for clinical practice can be two- or multi-dimensional.

Two-Dimensional. The grading systems for clinical practice are often two-
dimensional, such as pass/fail; satisfactory/unsatisfactory; met/did not meet
clinical objectives. Categories such as pass/fail and satisfactory/unsatisfactory
place emphasis on giving feedback to the learner because only two categories of
performance need to be determined.

The advantage of two-dimensional systems is that it is easier to make
distinctions between acceptable and unacceptable performance. The major
disadvantage of that approach is that it does not reward exceptional
performance.

Multi-Dimensional. Multi-dimensional grading systems include using letter
grades, usually A through F; integers, such as 5 through 1; or percentages. The
primary advantage of multi-dimensional systems is that it can reward superior
performance. However, its major disadvantage is that it is difficult to discriminate
among four of five levels of performance.

Regardless of the grading system for clinical practice, there are two criteria that
must be met:

1. The evaluation strategies for the collection of data about student
performance should reflect the clinical competencies and outcomes for
which a grade will be assigned; and

2. Students must understand how their clinical practice will be evaluated and
graded (Gaberson & Oermann, 2007).



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REFERENCES


American Association of College of Nurses. (1996). Essentials of masters
education for advanced practice nursing. Washington, DC: Author.

American Association of College of Nurses. (2008). Essentials of baccalaureate
education for professional nursing practice. Washington, DC: Author.

American Nurses Association. (2001). Code of ethics for nurses with interpretive
statements. Silver Spring, MD: Author.

Derickson, L. M. & Caputi, L. (2004). Teaching the critical thinking skills of
delegating and prioritizing. In. L Caputi & Englemann (Eds) Teaching nursing:
The art and science (pp. 681-695) Glen Ellyn, IL: College of DuPage Press.

Gaberson, K. B. & Oermann, M. H. (2007). Clinical teaching strategies in
nursing, (2
nd
edition). New York: Springer Publishing.

Liberto, T., Roncher, M., & Shellenberger, T. (1999). Anecdotal notes: Effective
clinical evaluation and record keeping. Nurse Educator, 24(6), 15-18.

Yoder-Wise, P. S. (2003). Leading and managing in nursing (3
rd
edition). St.
Louis: Mosby.