Joanne Noone, PhD, RN, CNE April 20-21, 2015 This symposium outlines a clinical education model developed and implemented in the Oregon Consortium for Nursing Education undergraduate curriculum to best prepare nurses to practice in the 21st century. From Random to Targeted Clinical Learning: The Oregon Clinical Education Model OHSU School of Nursing www.ohsu.edu/son

Oregon Consortium for Nursing Education (OCNE) Shared competency-based curriculum to prepare nurses to work in the 21st century 5 OHSU and 9 CC partners 3 year nursing curriculum

Clinical Education Redesign Key Questions What are the purposes of clinical education? Is total patient care the best approach to achieve these goals? What are the problems with the conventional approach to clinical education? NLN Prelicensure Survey (2008) – many of the strategies identified by faculty to overcome barriers to clinical learning perpetuated total patient care model

Clinical Education Redesign Group 32 academic and practice partners across the state Identified assumptions for learner centered clinical education Developed model Expectations of students, clinical partners and faculty Intentional design of learning activities Linked to developmental needs of learner

Clinical Education Model This clinical education model moves away from a “random access opportunity” model of clinical education reliant on “total patient care” experiences to an intentional design of learning activities based on course competencies appropriate to student level. It is intended to promote deep understanding of knowledge and skills used for providing patient care and to structure clinical experiences appropriate to identified learning outcomes and the developmental level of the student.. Expectations for faculty, students and clinical staff were outlined to enhance quality in clinical learning. Five elements of the models were proposed From random access to purposeful design

Concept Based What are some important concepts to use as building blocks? Focus is on developing pattern recognition Fluid/Electrolyte Balance Diabetes Concept-based learning focuses on a concept to be used as foundational building blocks to aid in developing pattern recognition.

Diabetes CBLA Instructors: Find 2 or 3 diabetic patients. Look for patients with scheduled medication for their diabetes. There may be differing intensity of treatment from correction bolus insulin or daily dosing. Look for patients with differing causes for their diabetes. Students may work together in small groups of 2 to 3. Work should be completed within the clinical day so that debrief can occur in post conference. Bring monofilaments for use in assessments.

Diabetes CBLA - Patterns Medication regimen Predisposing factors – history Complications Blood sugar patterns Other lab values – HgbA1C, Cholesterol, estimated GRF, microalbuminemia Focused assessment Lived experience Learning needs

Case Based Simulation Involves authentic clinical problems Highly prevalent nursing practice situations Includes simulated learning experiences “Mega-cases” exemplars of prevalent health care situations Case-based learning experiences are clinical exemplars, often delivered through simulation, to enhance developing clinical judgement Purpose of this clinical activity is to teach students to think like a nurse through exposure to client case exemplars. Essential Characteristics Involve authentic clinical problems Highly prevalent nursing practice situations Encompasses seminar discussion of written, simulated or computer-based cases Includes a variety of simulated learning experiences including use of hi and lo tech manikins, standardized patients and role-playing. The OCNE curriculum includes a number of “mega-cases” that are designed as exemplars of highly prevalent health care situation.

Bringing MegaCases to Life Follow-up to in-class case work Faculty/theater student can play Mega Case role Gives students a chance to follow through on what more they would like to know Script out some possible responses

Adolescent Standardized Patients Adolescents recruited by community Health Educator They create their character Student nurses become intake nurses Complete sexual health history and assessment Students both observe and do an interview Debriefing occurs with patient

Simulations that Focus on Vulnerable Populations Schizophrenia Simulation Poverty Simulation Veteran Simulations

Intervention Skill Based Beyond technical skills Includes developing skill with communication and assessment Linked with preparatory and reflective assignments A person at the flu clinic tells you he got a flu shot in September and is getting a second one today “for insurance”. How should you respond? Another client at the flu clinic asks you, “Why do I need to get a flu shot every year?” How should you answer? Intervention skill-based learning occurs through repetition of psychomotor, assessment and communication skill-building.

Focused Direct Client Care Essential Characteristics Student applies knowledge and skill base “Client” includes individual, families and communities Student incorporate into the workflow of the agency Students learn to engage in constant organization and prioritization “Focused” differentiates it from the concept “total patient care” with the “focus” identifying the learning expectations and based on the course outcomes and student developmental level. Students learn to establish and nurture the nurse/client relationship and integrate the ethics of caring for individuals. Students learn to incorporate the workflow of the agency into the care they are providing. Students begin to learn to engage in the constant organization and prioritization activity that is required in dynamic care environments. During mid-level clinical experiences, focused direct client care is used for the student to gain progressive experience in the actual delivery of nursing care in acute care, transitional care and community settings

Integrative Experience Pulls all elements of prior learning into an authentic clinical situation Begins the transition into practice Student assigned to Clinical Teaching Associate This is also an opportunity for the student to be integrated into the practice community and transition from the student to the professional nurse role. The student practices integration of knowledge, clinical judgment and competencies while providing client care and studies the role of the registered nurse as it is expressed in a particular organizational environment. Characteristics of a good integrative experience include opportunities for the student to practice nursing in an organizational context including experience with the rules, norms, culture and infrastructure

Early Clinical Learning Experiences Concept Based Case Based Intervention-Skill Based Direct- Focused Care In early clinical learning, concept-based, case-based and intervention skill-based elements are dominant.

Mid-Program Learning Experiences Case Based Focused Direct Patient Care Concept Based Intervention- Skill Based

End of Program Learning Experiences II Integrative Experience Concept- Based Intervention- Skill Based Case-Based Integrative clinical experiences dominate in late clinical learning and provide an opportunity for the student to pull elements of prior learning into an authentic clinical practice situation to begin transition into practice.

Working with Clinical Partners Goal cards/Handouts “They think now and just don’t perform tasks” (Staff Development Educator) “Assignments impact the real world of nursing and are not just an exercise for students to do” (Nursing administrator at local clinic)

“What impact has OCNE had on the way you teach?” 1) increased use of case studies; 2) increased use of simulation; 3) focus on deep learning/change in content coverage; 4) team teaching; 5) interactive learning activities for students. Oregon Consortium for Nursing Education (OCNE). Do not replicate without permission.

Faculty Survey - 2010 Oregon Consortium for Nursing Education (OCNE). Do not replicate without permission.

Student/Faculty Interaction “I am not running around the whole shift wondering what my students are doing unobserved when they have the responsibility for care and I am not in the room” “While I am still busy, it is focused on the learning of the student and not keeping the patient safe”

Win-win situations – students learning and contributing to agencies Best Things Observed Win-win situations – students learning and contributing to agencies Key learning and reflection Students are really thinking and grasping concepts - “CBLA’s and high fidelity simulation – 2 pieces of learning I never want to be without” (CC nursing director)

Questions? Joanne Noone Thank you noonej@ohsu.edu OHSU School of Nursing www.ohsu.edu/son