- Email: [email protected]
In defense of clinical conferences in clinical nursing education
Nurse Education in Practice 16 (2016) 269e273
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
In defense of clinical conferences in clinical nursing education Toni M. Vezeau* Seattle University College of Nursing, 901 12th Avenue, Seattle, WA 98122, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 6 October 2015
Clinical conferencing has been a consistent feature of clinical education, but the current clinical education environment poses many challenges to its continuance. The paper raises concern regarding the current state of clinical conferencing as part of clinical practice education in nursing. This topic is of great concern, but has there is little direction for clinical educators. The paper reviews the literature on conferencing and recommends avenues for future research. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Clinical conference Learning environment Clinical students Nursing Baccalaureate education Clinical education
As a nurse educator for over two decades, I am often frustrated by lost opportunities and by a general lack of an evidence-based approach in nursing education. In recent years nursing research is attempting to build a knowledge base through which educators can determine best practices. The area most in need of investigation and evaluation is in clinical education. Benner et al. (2010) call for a transformation of nursing education, both highlighting clinical education as a key focus. There is scant literature to support or shed specific practices, and the current clinical education environment is changing so rapidly, educators are adjusting teaching strategies in response. In my local environment there is discussion about the relative value of clinical conferences, particularly from novice faculty who are frustrated with the logistics, constraints, and novelty of this clinical education component. I worry that educators may dismiss the clinical conference as historical artifact, when in fact, it accomplishes those very goals that we are called upon to improve in clinical education. This paper attempts to revisit the opportunities that clinical conferencing offers, and discuss the current obstacles and challenges for the nurse educator in facilitating effective conferences. Clinical conferences have been a prominent and challenging aspect of nursing clinical education (Ascano-Martin, 2008; Hsu, 2007; Yehle and Royal, 2010). The clinical conference has been designed to fulfill multiple aspects of student learning: integration of theoretical concepts and practice experiences, support in the affective domain, and professional role development (Hsu, 2007;
* Tel.: þ1 206-296-2215; fax: þ1 206 296 5544. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.nepr.2015.10.006 1471-5953/© 2015 Elsevier Ltd. All rights reserved.
Ironside, 1999; Letizia, 1998; Wink, 1993, 1995). Current trends in the delivery of clinical education, however, provides certain obstacles that call into question the usefulness and feasibility of this and other standards in clinical education (Adegbola, 2011; Tanner, 2006). Not only has the clinical learning environment changed, but so has the learner; contemporary students may require alternate approaches to reflective knowledge and professional development (Pardue and Morgan, 2008; Rassool and Rawaf, 2007; Tanner, 2006). Clinical conferences in format are as varied as the faculty teaching them. Conferences often are held during or following the clinical experience. For convenience, they are often held at the clinical site in a private setting. Conferences often have students review their clinical day, highlighting key learning experiences, inclusive of positive and concerning experiences. Typically student members of the group comment on these shared experiences. However, the purposes of clinical conferences have been reported consistently in the literature: exploring connections between theoretical knowledge and lived experiences as learning nurses, expression and integration of feelings and experiences, support and recommendations for coping, and planning for future learning (Yehle and Royal, 2010). This conceptual article draws on the author's teaching and mentoring experiences and recent student and faculty evaluations. The goal is to examine the original purposes of clinical conferences in light of today's constraints to propose that the benefits of conferencing outweigh the costs. Recommendations for pedagogy and research are offered to further a scholarly approach in clinical nursing education.
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T.M. Vezeau / Nurse Education in Practice 16 (2016) 269e273
Literature on clinical conferences Research and discussion about clinical conferences has been minimal in nursing literature. A large portion of the clinical hours typically are typically represented by clinical conference time. Wink in 1995 stated that up to 30% of clinical hours were allocated to conferencing. Currently, this figure is closer to 10e15% of clinical hours in our region (Dean Stauffer, personal communication). Despite this significant use of clinical time, there is little reported on typical patterns and approaches. The first specific discussion of clinical postconference by Lister (1966) and Matheny (1969) laid a foundation identifying the purposes of clinical conferences and are still cited today. In the 1980s calls for research to better understand this important component of clinical teaching (McCabe, 1985; Mitchell and Krainovich, 1982; Woolley and Costello, 1988) have largely gone unheeded. In a review of healthcare literature from 1995 to 2012 in PubMed and CINAHL, only twelve articles were found, using MeSH heading “Education, Nursing/methods,” “Nursing Education Research,” alone and in combination with keywords: conference, clinical, seminar. Of the 12 articles, 9 addressed nursing education, 5 were data-based, and 4 were descriptive. The articles provides evaluative information (Hsu, 2007; Rossignol, 2000); showcase specific techniques, such as audio teleconferencing (Adegbola, 2011), and use of higher level questions (Wink, 1993), and activities to stimulate discussion (Letizia, 1998). In sum, the available information, particularly evidence-based, is sparse, given the number of hours allotted to conferencing. Nursing educators throughout the country continue the practice of postconferencing without empirical evidence supporting the educational benefits of this activity. Although many authors have published ideas, techniques, and opinions regarding the use of postconference time in nursing education, there is a fundamental lack of data-based research regarding this issue. (Letizia and Jennrich, 1998, p. 317) Despite paucity of empirical evidence, conventional wisdom suggests that conferencing enhances student learning (Hermann, 2006; Letizia and Jennrich, 1998). In response to this gap, Letizia and Jennrich developed the Post-Conference Learning Environment Survey, a self-report instrument aimed at measuring aspects of the post-conference learning environment as perceived by undergraduate nursing students and faculty. The tool had multi-site validation, but sadly, this structured and interesting approach to developing our knowledge and expertise on effective conferencing has not been replicated. The scant literature on clinical conferencing does come to some conclusions. An effective clinical conference is essential to clinical learning, and may be in part what distinguishes an effective educator (Hermann, 2006; Wink, 1993, 1995). Clinical conferences should be intentional, with attention to timing, environmental, and the student as a whole person, addressing not only cognitive aspects of learning, but affective aspects as well. The purposes of clinical conferences are better accomplished with students as engaged actors, rather than fatigued, passive recipients (Adegbola, 2011; Wink, 1995; Yehle and Royal, 2010). Purposes of clinical conferences Clinical conference is one of the primary vehicles for linking theory taught in the classroom to the experiences students have in clinical settings. Faculty help the student report on the day's experiences and actively help in the student's identify whether the practices they participated in were congruent or dissonant with the
didactic content (Corlett, 2000). For example, in my own area of childbearing families, classroom content presents the most current evidence-based care modalities, but what the student experiences is often at odds: poor patient advocacy and common use of unnecessary or dangerous interventions. Students report distress when there is a seeming mismatch between the broad and seemingly straightforward content taught in the classroom and the messy, very human, clinical experiences (Corlett, 2000). Conferences can help students in a public venue apply theoretical concepts to the particularity of a deeply nuanced patient situation, flavored by cultural, economic, political, and historical variables e and most especially flavored by constant change. Skilled faculty are needed to interpret the setting and to help the student discover the context that drives the dissonance. Clinical settings that are changing to more evidence-based approaches have to resolve conflicts from many constituencies and contextual variables, and, essentially, takes time to put into place. While we hope as faculty to place students in the most up-to-date settings, necessity dictates that what students actually experience are clinical sites in the constant process of change. Faculty can assist the students in the integration of their knowledge sets in the service of understanding a particular patient situation; students are helped to bring multiple lens - biological, medical, sociocultural, ethical, historical, political e to clarify how the patient context evolved, and how it will be affected in healthcare. In many ways, clinical conferences represent a pure form of problem-based learning, wherein the “problems,” patient situations, have been engaged in the real world and student has had to grapple with real-time discernment and decision-making. This discernment is aligned with Tanner's (2006) call for nurse educators to not waste precious student clinical time and to develop specific strategies that actively encourage enhanced critical reasoning. Adept questioning in conferences can assist this development. Wink's (1995) and Hermann's (2006) work offer approaches to identify high level questioning by faculty in conferencing. High level cognitive questioning can develop critical reasoning in an open venue with inherent feedback opportunities. Conferences offer breadth as well as depth. Students who are often enmeshed in a single patient care situation can benefit from hearing about their peers' experiences, and encouraged to see similarities and differences, hence gaining increased knowledge from peer reporting and analysis. This provides faculty an opportunity to help students use particular situations to construct models that parallel their didactic models; concept mapping is one common strategy used to achieve this outcome (Pilcher, 2011). Beyond cognitive development, clinical conference can assist the student in the affective domain. Clinical experiences can be challenging, frightening, and overwhelming to students. Students who witness birth have strong personal reactions as do those students who witness death for the first time in their professional role. Clinical conference can provide a safe environment for the student to disclose personal feelings and to gain peer support in what are often difficult learning situations. Students can discuss their own triumphs and fears in learning the reality aspects of the profession. Faculty can help students contextualize these discussions in broader picture of professional development. Innovation can be sparked by encouraging students to move beyond acceptance of what they experienced to imagining better use of evidence-based approaches in creative ways. Finally, in clinical conferences students can form more connected relationships with their faculty, who can provide leadership and role-modeling for professional nursing. Clinical conference is often where students spend the majority of their time with their clinical faculty in deep and public discernment and highlight this connection as pivotal to clinical learning (Gillespie, 2005). Gillespie
T.M. Vezeau / Nurse Education in Practice 16 (2016) 269e273
and Allison-Jones and Hirt (2004) emphasize the transformative possibilities in studentefaculty relationships. Students can be publicly affirmed and develop an understanding of their potential professional abilities. The setting of clear ground rules for conferences, such as required attendance, critiquing ideas rather than the person, the acknowledgment and acceptance of feedback, the expectation that all persons participate help students understand professional norms and develop local leadership. This author is quite concerned should clinical conferencing be entirely deleted or relegated to purely virtual, that is, electronic discussion, post facto. Students and faculty can best process difficult learning situations in a timely and contextualized manner. Discussions that occur many hours or days after the clinical experience have lost their immediacy and importance in lieu of more pressing immediate school concerns. Intervening conversations are likely to occur without faculty input and guidance, which likely would alter what would be shared in an online chat/discussion group, for example. Nonverbal communication of the group is lost when the discussion moves to an electronic venue. The opportunity for a faculty to move fluidly from discussion to didactic clarification and back to the group would be entirely lost. Most important to this author, is the missing and timely support that clinical conferencing affords the student, which role-models future professional behaviors to students. The clinical conference can help the student to integrate and contextualize their clinical experiences and to help them become professional nurses. This is not easily accomplished, however, in today's clinical education environment. Constraints and challenges The typical pattern of clinical conference often does not work in today's clinical environment. Historically, conferences have been held after an eight-hour day shift experience at the clinical site. Students often report on their experiences and housekeeping items are reviewed. Students and faculty both are often physically and mentally fatigued (Adegbola, 2011; Yehle and Royal, 2010). It is difficult to find private meeting spaces on site, and literature suggests that completing clinical work to even attend the conference is a constant challenge. Clinical experiences may no longer be the eight-hour shift, but is often on evenings or nights, and may be any number of hours, ranging from 4 to 12 (Mariani et al., 2012). Timing of clinical conferences, may now be preclinical, to assess student preparation and readiness for patient care or held after the clinical experiences are over. Conferencing may also occur during breaks, often interrupting the clinical day and potentially limiting the student in their role as an essential part of the care team. If one adds the increased acuity and pace of clinical settings with longer and non-daytime hours, it is easy to understand how the original intents of clinical conference are challenging to meet. Critical reasoning and deep reflection is unlikely occur for exhausted clinical group members. The composition of the group itself in many clinical teaching environments may not be stable from week to week. The surge in nursing program enrollment (Terry and Whitman, 2011) and increased push back from overwhelmed clinical agencies, clinical groups may be large (over 10), but may only be allowed to have 7e8 students on site at the same time. Students are “spun off” to observational experiences in or out of the agency; these hidden students may have hours that differ from the sub-group meeting in conferences. Essentially, the group itself changes from week to week, making group process an ever-moving target and the logistics of a clinical conference is very challenging. This has resulted in some unique problem-solving with use of teleconferencing (Adegbola, 2011) and online discussion groups (Hermann, 2006).
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The few studies on the quality of conferencing have questioned the effectiveness of this component of clinical teaching. Multiple studies have noted that the level of discussion and rigorous questioning is typically low level (Hsu, 2007; Rossignol, 2000; Wink, 1995). Description and comprehension level discussion are usually observed in the typical clinical conference, but higher levels of reasoning, application and synthesis, may be largely absent. This lack of strong pedagogy observed in conferences could be due to the increased use of adjuncts or part-time faculty assigned to clinical teaching. Use of part-time faculty has increased by 53% from 2005 to 2010 and accounts for half of all nursing faculty (Mangan, 2011; Terry and Whitman, 2011). Kelly (2007) echoes this concern and states that nursing education programs have diminishing numbers of experienced faculty and that the “casual” or intermittent nurse educator is poorly prepared. Competency and effectiveness of clinical teaching has been shown to be very different between full-time and part-time faculty (Allison-Jones and Hirt, 2004). Clinical conference poses unique teaching challenges for novices. Conference often responds to the needs of the moment and often requires improvisation informed by clear purpose. However, unstructured and unfocused discussion can often be seen as unimportant or boring by students and faculty (Letizia, 1998). Hsu (2007) recommends that the faculty skills in delivering effective conferences can be developed through faculty development activities. Faculty development can develop understanding of the purposes of clinical conferences and group facilitation strategies. Equally important, observation and feedback to clinical faculty need to be a core component to faculty development, especially for the novice clinical faculty. Finally, the current nursing student may have unique learning needs and preferences. Literature in the mid-2000s points out that nursing students themselves are changing variables in clinical education. Rassool and Rawaf (2007) assessed learning styles of undergraduate nursing students and found a strong mismatch between the teaching styles of nursing faculty and the preferences of the students. Despite faculty encouragement for participation, active learning, and experimentation by students, this study indicated that students preferred a more observational style and seemed more guarded and quiet. Students stated they least preferred an activist style. In contrast to these findings, Skiba and Barton (2006) suggest that students do prefer a very active, multi-modal approach to learning. They recommend altering our clinical education not only to address multiple learning styles, but also to address generational changes e specifically, the unique characteristics of the millennial or “Net” generation, those students born between 1982 and 1991. This generation seems to be at odds with Rassool's and Rawaf's assessment in that the millenials may prefer more experiential, less abstract learning, and have a “bias toward action” (Skiba and Barton, 2006, para. 11). According to Skiba and Barton, millenials like to express their views and use experiences to expand their learning, which should add to the potential of conferencing. Use of technology is seen as a learning style, and is actively used to fill in the gaps of their knowledge and to validate the faculty's. Collaborative learning is welcomed by this generation. Slow, delayed learning is intolerable. Millennials are strong team players these preferences may indicate is that the typical round-robin reporting that is often done in conference runs counter to this learning style. Faculty may need help to develop a repertoire of interactive engaging activities that are consistent with this generation's needs so that conferencing fulfills its many purposes. Faculty who continue in teacher-centered or passive learning approaches may misinterpret students' non-participation as unwillingness to share
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or that the conference as itself is a waste of time. Again, novice or intermittent educators may need development to address the unique needs of today's learners (Allison-Jones and Hirt, 2004). Difficulty in researching clinical conferences The question then becomes so what are best practices that we can share with interested or novice colleagues that could support effective conferences? The scant literature on clinical conferences, like this paper, is descriptive in nature, most often written by highly experienced faculty. While anecdotal, experiential recommendations can be very worthwhile, nurse educators need to move toward building evidence for best practices. There are considerable difficulties in trying to research best practices for clinical conferences. Some studies have been observational, investigating the rigor of questions in conference, sharing of leadership and power with students, and some have gathered descriptive data on using a particular type of conference delivery, typically synchronous or non-synchronous technology approaches. The goal has not been to seek best practices, per se, so educators wishing to research in this area have little foundation. Wink (1993, 1995) proposed characteristics of effective clinical conferences (group event, contributes to meeting course objectives, and allows for discussion of feelings and attitudes), but these have not been tested as yet. Most studies cited in this paper do not take into account the skills and background of the faculty or the level of student. Best practices on clinical conferences should be highly sensitive to the level of student learning. Beginning clinical students may be novice to frank group discussion with public reflection and critical reasoning, and so a good deal of time is spent in forming and norming activities. Students near the end of a nursing program may benefit from a more collaborative approach in which they actively lead and construct the conference format and content (Rossignol, 2000). Tanner (2006) calls for aligning our clinical activities to address specific learning outcomes. The rub with clinical conference is that, in part, facilitation of clinical conference is improvisational. Faculty glean from the day highlights that might bring about the integration of theory and practice; these highlights cannot be anticipated or prepared prior. There is often a bounty of unique client situations that students can delve into to explore connections to previous learning, to understand what occurred, and to imagine alternate possibilities. For example, one day a student may experience a highly interventionist birth in the same day as witness a physiologic low-technological birth. Another student may experience tensions related informed consent and advocacy with conflict among the health care team. The faculty, particularly the novice faculty, may be challenged in identifying useful discussion areas and in having the skills to facilitate students bringing depth and breadth to the dialogue. The physical environment and timing and have not been addressed through research. The Post-Conference Learning Environment Survey (Letizia and Jennrich, 1998) surveyed student and faculty perceptions of actual participation and beliefs on the importance of different aspects the conference demonstrates a rigorous approach to identify beliefs and attitudes, but it is unknown to what degree conferencing actually achieved its multiple purposes. Next steps As with many areas of nursing education, there is a need for educators to develop an evidence-based foundation to our methods. Our next steps may lie in replication of Rossignol's survey
in today's environment or testing out the earlier statements on conferencing by experienced faculty. Research can investigate if the needs of beginning clinical students and close-to-exit students have differing needs in group conferences. We can test if face-toface group meetings are best to capitalize on the immediacy of the student experiences when conferences immediately follow, or if there is enhanced reflection and reframing when conducted outside of the agency when both student and faculty are rested. We can test if there is improved integration of theory and practice if conferences are face to face or held with all persons present in real time and space. Given the considerable resources used and the potential opportunities in clinical conferences, these are important questions for nurse educators to answer. Of most concern to this writer that we do not discard a key component of clinical education, because it is hard to do and we currently lack much empirical evidence as to its overall effectiveness and best practices. A research program on clinical conferences would need to be multi-site and multi-faceted and could yield valuable direction. References Allison-Jones, L.L., Hirt, J.B., 2004. Comparing the teaching effectiveness of parttime and full-time clinical nurse faculty. Nurs. Educ. Perspect. 25 (5), 238e243. Adegbola, M., 2011. Taking learning to the learner: using audio teleconferencing for postclinical conferences and more. Creat. Nurs. 17 (3), 120e125. Ascano-Martin, F., 2008. Shift report and SBAR: strategies for clinical post-conference. Nurse Educ. 33 (5), 190e191. http://dx.doi.org/10.1097/ 01.NNE.0000334779.90395.67. Benner, P., Sutphen, M., Leonard, V., Day, L., 2010. Educating Nurses: a Call for Transformation. Jossey-Bass, San Francisco, CA. Corlett, J., 2000. The perceptions of nursing teachers, student nurses and preceptors of the theory-practice gap in nurse education. Nurse Educ. Today 20 (6), 499e505. http://dx.doi.org/10.1054/nedt.1999.0414. Gillespie, M., 2005. Student-teacher connection: a place of possibility. J. Adv. Nurs. 52 (2), 211e219. http://dx.doi.org/10.1111/j.1365-2648.2005.03581.x. Hermann, M.L., 2006. Technology and reflective practice: the use of online discussion to enhance postconference clinical learning. Nurse Educ. 31 (5), 190e191. Hsu, L., 2007. Conducting clinical post-conference in clinical teaching: a qualitative study. J. Clin. Nurs. 16 (8), 1525e1533. http://dx.doi.org/10.1111/j.13652702.2006.01751.x. Ironside, P.M., 1999. Thinking in nursing education: Part I. A student's experience learning to think. Nurs. Healthc. Perspect. 20 (5), 238e242. Kelly, C., 2007. Student's perceptions of effective clinical teaching revisited. Nurse Educ. Today 27 (8), 885e892. http://dx.doi.org/10.1016/j.nedt.2006.12.005. Letizia, M., 1998. Strategies used in clinical post-conference. J. Nurs. Educ. 37 (7), 315e317. Letizia, M., Jennrich, J., 1998. Development and testing of the clinical postconference learning environmental survey. J. Prof. Nurs. 14 (4), 206e213. Lister, D.W., 1966. The clinical conference. Nurs. Forum 5 (3), 84e94. Mangan, K., May 31, 2011. Nursing schools increasingly turn to part-time faculty. Chron. High. Educ. [online]. Accessed at: http://chronicle.com/article/NursingSchools-Increasingly/127727/?sid¼at&utm_source¼at&utm_medium¼en. Mariani, B.A., Arcamone, A., Cummins, J., 2012. Student and Register Nursing Staff's Perceptions of 12-hour Clinical Rotations in an Undergraduate Baccalaureate Nursing Program. Sigma Theta Tau 41 Biennial Convention. Accessed at: http:// hdl.handle.net/10755/201914. Matheny, R.V., 1969. Pre and post conferences for students. Am. J. Nurs. 69 (2), 286e289. McCabe, B., 1985. The improvement of instruction in the clinical area: a challenge waiting to be met. J. Nurs. Educ. 24 (6), 255e257. Mitchell, C.A., Krainovich, B., 1982. Conducting pre and post conferences. Am. J. Nurs. 82, 823e825. Pardue, K.T., Morgan, P., 2008. Millenials considered: a new generation, new approaches, and implications for nursing education. Nurs. Educ. Perspect. 29 (2), 74e79. Pilcher, J., 2011. Teaching and learning with concept maps. Neonatal Netw. 30 (5), 336e339. http://dx.doi.org/10.1891/0730-0832.30.5.336. Rassool, G.H., Rawaf, S., 2007. Learning style preferences of undergraduate nursing, students. Nurs. Stand. 21 (32), 35e41. Rossignol, M., 2000. Verbal and cognitive activities between and among students and faculty clinical conferences. J. Nurs. Educ. 39 (6), 245e250. Skiba, D.J., Barton, A.J., 2006. Adapting your teaching to accommodate the net generation of learners. Online J. Issues Nurs. (OJIN) 11 (2). http://dx.doi.org/ 10.3912/OJIN.Vol11No02Man04. Manuscript 4. Tanner, C.A., 2006. The next transformation: clinical education. J. Nurs. Educ. 45 (4), 99e100.
T.M. Vezeau / Nurse Education in Practice 16 (2016) 269e273 Terry, A.J., Whitman, M.V., 2011. Impact of the economic downturn on nursing schools. Nurs. Econ. 29 (5), 252e264. Wink, D.M., 1993. Effect of a program to increase the cognitive level of questions asked in clinical conferences. J. Nurs. Educ. 32 (8), 357e363. Wink, D.M., 1995. The effective clinical conference. Nurs. Outlook 43 (1), 29e32.
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Woolley, A., Costello, S., 1988. Innovations in clinical teaching. In: Curriculum Revolution: Mandate for Change. National League for Nursing, New York: NY. Yehle, K.S., Royal, P.A., 2010. Changing the postclinical conference: new time, new place, new methods equal success. Nurs. Educ. Perspect. 31 (4), 256e258.
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
In defense of clinical conferences in clinical nursing education Toni M. Vezeau* Seattle University College of Nursing, 901 12th Avenue, Seattle, WA 98122, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 6 October 2015
Clinical conferencing has been a consistent feature of clinical education, but the current clinical education environment poses many challenges to its continuance. The paper raises concern regarding the current state of clinical conferencing as part of clinical practice education in nursing. This topic is of great concern, but has there is little direction for clinical educators. The paper reviews the literature on conferencing and recommends avenues for future research. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Clinical conference Learning environment Clinical students Nursing Baccalaureate education Clinical education
As a nurse educator for over two decades, I am often frustrated by lost opportunities and by a general lack of an evidence-based approach in nursing education. In recent years nursing research is attempting to build a knowledge base through which educators can determine best practices. The area most in need of investigation and evaluation is in clinical education. Benner et al. (2010) call for a transformation of nursing education, both highlighting clinical education as a key focus. There is scant literature to support or shed specific practices, and the current clinical education environment is changing so rapidly, educators are adjusting teaching strategies in response. In my local environment there is discussion about the relative value of clinical conferences, particularly from novice faculty who are frustrated with the logistics, constraints, and novelty of this clinical education component. I worry that educators may dismiss the clinical conference as historical artifact, when in fact, it accomplishes those very goals that we are called upon to improve in clinical education. This paper attempts to revisit the opportunities that clinical conferencing offers, and discuss the current obstacles and challenges for the nurse educator in facilitating effective conferences. Clinical conferences have been a prominent and challenging aspect of nursing clinical education (Ascano-Martin, 2008; Hsu, 2007; Yehle and Royal, 2010). The clinical conference has been designed to fulfill multiple aspects of student learning: integration of theoretical concepts and practice experiences, support in the affective domain, and professional role development (Hsu, 2007;
* Tel.: þ1 206-296-2215; fax: þ1 206 296 5544. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.nepr.2015.10.006 1471-5953/© 2015 Elsevier Ltd. All rights reserved.
Ironside, 1999; Letizia, 1998; Wink, 1993, 1995). Current trends in the delivery of clinical education, however, provides certain obstacles that call into question the usefulness and feasibility of this and other standards in clinical education (Adegbola, 2011; Tanner, 2006). Not only has the clinical learning environment changed, but so has the learner; contemporary students may require alternate approaches to reflective knowledge and professional development (Pardue and Morgan, 2008; Rassool and Rawaf, 2007; Tanner, 2006). Clinical conferences in format are as varied as the faculty teaching them. Conferences often are held during or following the clinical experience. For convenience, they are often held at the clinical site in a private setting. Conferences often have students review their clinical day, highlighting key learning experiences, inclusive of positive and concerning experiences. Typically student members of the group comment on these shared experiences. However, the purposes of clinical conferences have been reported consistently in the literature: exploring connections between theoretical knowledge and lived experiences as learning nurses, expression and integration of feelings and experiences, support and recommendations for coping, and planning for future learning (Yehle and Royal, 2010). This conceptual article draws on the author's teaching and mentoring experiences and recent student and faculty evaluations. The goal is to examine the original purposes of clinical conferences in light of today's constraints to propose that the benefits of conferencing outweigh the costs. Recommendations for pedagogy and research are offered to further a scholarly approach in clinical nursing education.
270
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Literature on clinical conferences Research and discussion about clinical conferences has been minimal in nursing literature. A large portion of the clinical hours typically are typically represented by clinical conference time. Wink in 1995 stated that up to 30% of clinical hours were allocated to conferencing. Currently, this figure is closer to 10e15% of clinical hours in our region (Dean Stauffer, personal communication). Despite this significant use of clinical time, there is little reported on typical patterns and approaches. The first specific discussion of clinical postconference by Lister (1966) and Matheny (1969) laid a foundation identifying the purposes of clinical conferences and are still cited today. In the 1980s calls for research to better understand this important component of clinical teaching (McCabe, 1985; Mitchell and Krainovich, 1982; Woolley and Costello, 1988) have largely gone unheeded. In a review of healthcare literature from 1995 to 2012 in PubMed and CINAHL, only twelve articles were found, using MeSH heading “Education, Nursing/methods,” “Nursing Education Research,” alone and in combination with keywords: conference, clinical, seminar. Of the 12 articles, 9 addressed nursing education, 5 were data-based, and 4 were descriptive. The articles provides evaluative information (Hsu, 2007; Rossignol, 2000); showcase specific techniques, such as audio teleconferencing (Adegbola, 2011), and use of higher level questions (Wink, 1993), and activities to stimulate discussion (Letizia, 1998). In sum, the available information, particularly evidence-based, is sparse, given the number of hours allotted to conferencing. Nursing educators throughout the country continue the practice of postconferencing without empirical evidence supporting the educational benefits of this activity. Although many authors have published ideas, techniques, and opinions regarding the use of postconference time in nursing education, there is a fundamental lack of data-based research regarding this issue. (Letizia and Jennrich, 1998, p. 317) Despite paucity of empirical evidence, conventional wisdom suggests that conferencing enhances student learning (Hermann, 2006; Letizia and Jennrich, 1998). In response to this gap, Letizia and Jennrich developed the Post-Conference Learning Environment Survey, a self-report instrument aimed at measuring aspects of the post-conference learning environment as perceived by undergraduate nursing students and faculty. The tool had multi-site validation, but sadly, this structured and interesting approach to developing our knowledge and expertise on effective conferencing has not been replicated. The scant literature on clinical conferencing does come to some conclusions. An effective clinical conference is essential to clinical learning, and may be in part what distinguishes an effective educator (Hermann, 2006; Wink, 1993, 1995). Clinical conferences should be intentional, with attention to timing, environmental, and the student as a whole person, addressing not only cognitive aspects of learning, but affective aspects as well. The purposes of clinical conferences are better accomplished with students as engaged actors, rather than fatigued, passive recipients (Adegbola, 2011; Wink, 1995; Yehle and Royal, 2010). Purposes of clinical conferences Clinical conference is one of the primary vehicles for linking theory taught in the classroom to the experiences students have in clinical settings. Faculty help the student report on the day's experiences and actively help in the student's identify whether the practices they participated in were congruent or dissonant with the
didactic content (Corlett, 2000). For example, in my own area of childbearing families, classroom content presents the most current evidence-based care modalities, but what the student experiences is often at odds: poor patient advocacy and common use of unnecessary or dangerous interventions. Students report distress when there is a seeming mismatch between the broad and seemingly straightforward content taught in the classroom and the messy, very human, clinical experiences (Corlett, 2000). Conferences can help students in a public venue apply theoretical concepts to the particularity of a deeply nuanced patient situation, flavored by cultural, economic, political, and historical variables e and most especially flavored by constant change. Skilled faculty are needed to interpret the setting and to help the student discover the context that drives the dissonance. Clinical settings that are changing to more evidence-based approaches have to resolve conflicts from many constituencies and contextual variables, and, essentially, takes time to put into place. While we hope as faculty to place students in the most up-to-date settings, necessity dictates that what students actually experience are clinical sites in the constant process of change. Faculty can assist the students in the integration of their knowledge sets in the service of understanding a particular patient situation; students are helped to bring multiple lens - biological, medical, sociocultural, ethical, historical, political e to clarify how the patient context evolved, and how it will be affected in healthcare. In many ways, clinical conferences represent a pure form of problem-based learning, wherein the “problems,” patient situations, have been engaged in the real world and student has had to grapple with real-time discernment and decision-making. This discernment is aligned with Tanner's (2006) call for nurse educators to not waste precious student clinical time and to develop specific strategies that actively encourage enhanced critical reasoning. Adept questioning in conferences can assist this development. Wink's (1995) and Hermann's (2006) work offer approaches to identify high level questioning by faculty in conferencing. High level cognitive questioning can develop critical reasoning in an open venue with inherent feedback opportunities. Conferences offer breadth as well as depth. Students who are often enmeshed in a single patient care situation can benefit from hearing about their peers' experiences, and encouraged to see similarities and differences, hence gaining increased knowledge from peer reporting and analysis. This provides faculty an opportunity to help students use particular situations to construct models that parallel their didactic models; concept mapping is one common strategy used to achieve this outcome (Pilcher, 2011). Beyond cognitive development, clinical conference can assist the student in the affective domain. Clinical experiences can be challenging, frightening, and overwhelming to students. Students who witness birth have strong personal reactions as do those students who witness death for the first time in their professional role. Clinical conference can provide a safe environment for the student to disclose personal feelings and to gain peer support in what are often difficult learning situations. Students can discuss their own triumphs and fears in learning the reality aspects of the profession. Faculty can help students contextualize these discussions in broader picture of professional development. Innovation can be sparked by encouraging students to move beyond acceptance of what they experienced to imagining better use of evidence-based approaches in creative ways. Finally, in clinical conferences students can form more connected relationships with their faculty, who can provide leadership and role-modeling for professional nursing. Clinical conference is often where students spend the majority of their time with their clinical faculty in deep and public discernment and highlight this connection as pivotal to clinical learning (Gillespie, 2005). Gillespie
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and Allison-Jones and Hirt (2004) emphasize the transformative possibilities in studentefaculty relationships. Students can be publicly affirmed and develop an understanding of their potential professional abilities. The setting of clear ground rules for conferences, such as required attendance, critiquing ideas rather than the person, the acknowledgment and acceptance of feedback, the expectation that all persons participate help students understand professional norms and develop local leadership. This author is quite concerned should clinical conferencing be entirely deleted or relegated to purely virtual, that is, electronic discussion, post facto. Students and faculty can best process difficult learning situations in a timely and contextualized manner. Discussions that occur many hours or days after the clinical experience have lost their immediacy and importance in lieu of more pressing immediate school concerns. Intervening conversations are likely to occur without faculty input and guidance, which likely would alter what would be shared in an online chat/discussion group, for example. Nonverbal communication of the group is lost when the discussion moves to an electronic venue. The opportunity for a faculty to move fluidly from discussion to didactic clarification and back to the group would be entirely lost. Most important to this author, is the missing and timely support that clinical conferencing affords the student, which role-models future professional behaviors to students. The clinical conference can help the student to integrate and contextualize their clinical experiences and to help them become professional nurses. This is not easily accomplished, however, in today's clinical education environment. Constraints and challenges The typical pattern of clinical conference often does not work in today's clinical environment. Historically, conferences have been held after an eight-hour day shift experience at the clinical site. Students often report on their experiences and housekeeping items are reviewed. Students and faculty both are often physically and mentally fatigued (Adegbola, 2011; Yehle and Royal, 2010). It is difficult to find private meeting spaces on site, and literature suggests that completing clinical work to even attend the conference is a constant challenge. Clinical experiences may no longer be the eight-hour shift, but is often on evenings or nights, and may be any number of hours, ranging from 4 to 12 (Mariani et al., 2012). Timing of clinical conferences, may now be preclinical, to assess student preparation and readiness for patient care or held after the clinical experiences are over. Conferencing may also occur during breaks, often interrupting the clinical day and potentially limiting the student in their role as an essential part of the care team. If one adds the increased acuity and pace of clinical settings with longer and non-daytime hours, it is easy to understand how the original intents of clinical conference are challenging to meet. Critical reasoning and deep reflection is unlikely occur for exhausted clinical group members. The composition of the group itself in many clinical teaching environments may not be stable from week to week. The surge in nursing program enrollment (Terry and Whitman, 2011) and increased push back from overwhelmed clinical agencies, clinical groups may be large (over 10), but may only be allowed to have 7e8 students on site at the same time. Students are “spun off” to observational experiences in or out of the agency; these hidden students may have hours that differ from the sub-group meeting in conferences. Essentially, the group itself changes from week to week, making group process an ever-moving target and the logistics of a clinical conference is very challenging. This has resulted in some unique problem-solving with use of teleconferencing (Adegbola, 2011) and online discussion groups (Hermann, 2006).
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The few studies on the quality of conferencing have questioned the effectiveness of this component of clinical teaching. Multiple studies have noted that the level of discussion and rigorous questioning is typically low level (Hsu, 2007; Rossignol, 2000; Wink, 1995). Description and comprehension level discussion are usually observed in the typical clinical conference, but higher levels of reasoning, application and synthesis, may be largely absent. This lack of strong pedagogy observed in conferences could be due to the increased use of adjuncts or part-time faculty assigned to clinical teaching. Use of part-time faculty has increased by 53% from 2005 to 2010 and accounts for half of all nursing faculty (Mangan, 2011; Terry and Whitman, 2011). Kelly (2007) echoes this concern and states that nursing education programs have diminishing numbers of experienced faculty and that the “casual” or intermittent nurse educator is poorly prepared. Competency and effectiveness of clinical teaching has been shown to be very different between full-time and part-time faculty (Allison-Jones and Hirt, 2004). Clinical conference poses unique teaching challenges for novices. Conference often responds to the needs of the moment and often requires improvisation informed by clear purpose. However, unstructured and unfocused discussion can often be seen as unimportant or boring by students and faculty (Letizia, 1998). Hsu (2007) recommends that the faculty skills in delivering effective conferences can be developed through faculty development activities. Faculty development can develop understanding of the purposes of clinical conferences and group facilitation strategies. Equally important, observation and feedback to clinical faculty need to be a core component to faculty development, especially for the novice clinical faculty. Finally, the current nursing student may have unique learning needs and preferences. Literature in the mid-2000s points out that nursing students themselves are changing variables in clinical education. Rassool and Rawaf (2007) assessed learning styles of undergraduate nursing students and found a strong mismatch between the teaching styles of nursing faculty and the preferences of the students. Despite faculty encouragement for participation, active learning, and experimentation by students, this study indicated that students preferred a more observational style and seemed more guarded and quiet. Students stated they least preferred an activist style. In contrast to these findings, Skiba and Barton (2006) suggest that students do prefer a very active, multi-modal approach to learning. They recommend altering our clinical education not only to address multiple learning styles, but also to address generational changes e specifically, the unique characteristics of the millennial or “Net” generation, those students born between 1982 and 1991. This generation seems to be at odds with Rassool's and Rawaf's assessment in that the millenials may prefer more experiential, less abstract learning, and have a “bias toward action” (Skiba and Barton, 2006, para. 11). According to Skiba and Barton, millenials like to express their views and use experiences to expand their learning, which should add to the potential of conferencing. Use of technology is seen as a learning style, and is actively used to fill in the gaps of their knowledge and to validate the faculty's. Collaborative learning is welcomed by this generation. Slow, delayed learning is intolerable. Millennials are strong team players these preferences may indicate is that the typical round-robin reporting that is often done in conference runs counter to this learning style. Faculty may need help to develop a repertoire of interactive engaging activities that are consistent with this generation's needs so that conferencing fulfills its many purposes. Faculty who continue in teacher-centered or passive learning approaches may misinterpret students' non-participation as unwillingness to share
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or that the conference as itself is a waste of time. Again, novice or intermittent educators may need development to address the unique needs of today's learners (Allison-Jones and Hirt, 2004). Difficulty in researching clinical conferences The question then becomes so what are best practices that we can share with interested or novice colleagues that could support effective conferences? The scant literature on clinical conferences, like this paper, is descriptive in nature, most often written by highly experienced faculty. While anecdotal, experiential recommendations can be very worthwhile, nurse educators need to move toward building evidence for best practices. There are considerable difficulties in trying to research best practices for clinical conferences. Some studies have been observational, investigating the rigor of questions in conference, sharing of leadership and power with students, and some have gathered descriptive data on using a particular type of conference delivery, typically synchronous or non-synchronous technology approaches. The goal has not been to seek best practices, per se, so educators wishing to research in this area have little foundation. Wink (1993, 1995) proposed characteristics of effective clinical conferences (group event, contributes to meeting course objectives, and allows for discussion of feelings and attitudes), but these have not been tested as yet. Most studies cited in this paper do not take into account the skills and background of the faculty or the level of student. Best practices on clinical conferences should be highly sensitive to the level of student learning. Beginning clinical students may be novice to frank group discussion with public reflection and critical reasoning, and so a good deal of time is spent in forming and norming activities. Students near the end of a nursing program may benefit from a more collaborative approach in which they actively lead and construct the conference format and content (Rossignol, 2000). Tanner (2006) calls for aligning our clinical activities to address specific learning outcomes. The rub with clinical conference is that, in part, facilitation of clinical conference is improvisational. Faculty glean from the day highlights that might bring about the integration of theory and practice; these highlights cannot be anticipated or prepared prior. There is often a bounty of unique client situations that students can delve into to explore connections to previous learning, to understand what occurred, and to imagine alternate possibilities. For example, one day a student may experience a highly interventionist birth in the same day as witness a physiologic low-technological birth. Another student may experience tensions related informed consent and advocacy with conflict among the health care team. The faculty, particularly the novice faculty, may be challenged in identifying useful discussion areas and in having the skills to facilitate students bringing depth and breadth to the dialogue. The physical environment and timing and have not been addressed through research. The Post-Conference Learning Environment Survey (Letizia and Jennrich, 1998) surveyed student and faculty perceptions of actual participation and beliefs on the importance of different aspects the conference demonstrates a rigorous approach to identify beliefs and attitudes, but it is unknown to what degree conferencing actually achieved its multiple purposes. Next steps As with many areas of nursing education, there is a need for educators to develop an evidence-based foundation to our methods. Our next steps may lie in replication of Rossignol's survey
in today's environment or testing out the earlier statements on conferencing by experienced faculty. Research can investigate if the needs of beginning clinical students and close-to-exit students have differing needs in group conferences. We can test if face-toface group meetings are best to capitalize on the immediacy of the student experiences when conferences immediately follow, or if there is enhanced reflection and reframing when conducted outside of the agency when both student and faculty are rested. We can test if there is improved integration of theory and practice if conferences are face to face or held with all persons present in real time and space. Given the considerable resources used and the potential opportunities in clinical conferences, these are important questions for nurse educators to answer. Of most concern to this writer that we do not discard a key component of clinical education, because it is hard to do and we currently lack much empirical evidence as to its overall effectiveness and best practices. A research program on clinical conferences would need to be multi-site and multi-faceted and could yield valuable direction. References Allison-Jones, L.L., Hirt, J.B., 2004. Comparing the teaching effectiveness of parttime and full-time clinical nurse faculty. Nurs. Educ. Perspect. 25 (5), 238e243. Adegbola, M., 2011. Taking learning to the learner: using audio teleconferencing for postclinical conferences and more. Creat. Nurs. 17 (3), 120e125. Ascano-Martin, F., 2008. Shift report and SBAR: strategies for clinical post-conference. Nurse Educ. 33 (5), 190e191. http://dx.doi.org/10.1097/ 01.NNE.0000334779.90395.67. Benner, P., Sutphen, M., Leonard, V., Day, L., 2010. Educating Nurses: a Call for Transformation. Jossey-Bass, San Francisco, CA. Corlett, J., 2000. The perceptions of nursing teachers, student nurses and preceptors of the theory-practice gap in nurse education. Nurse Educ. Today 20 (6), 499e505. http://dx.doi.org/10.1054/nedt.1999.0414. Gillespie, M., 2005. Student-teacher connection: a place of possibility. J. Adv. Nurs. 52 (2), 211e219. http://dx.doi.org/10.1111/j.1365-2648.2005.03581.x. Hermann, M.L., 2006. Technology and reflective practice: the use of online discussion to enhance postconference clinical learning. Nurse Educ. 31 (5), 190e191. Hsu, L., 2007. Conducting clinical post-conference in clinical teaching: a qualitative study. J. Clin. Nurs. 16 (8), 1525e1533. http://dx.doi.org/10.1111/j.13652702.2006.01751.x. Ironside, P.M., 1999. Thinking in nursing education: Part I. A student's experience learning to think. Nurs. Healthc. Perspect. 20 (5), 238e242. Kelly, C., 2007. Student's perceptions of effective clinical teaching revisited. Nurse Educ. Today 27 (8), 885e892. http://dx.doi.org/10.1016/j.nedt.2006.12.005. Letizia, M., 1998. Strategies used in clinical post-conference. J. Nurs. Educ. 37 (7), 315e317. Letizia, M., Jennrich, J., 1998. Development and testing of the clinical postconference learning environmental survey. J. Prof. Nurs. 14 (4), 206e213. Lister, D.W., 1966. The clinical conference. Nurs. Forum 5 (3), 84e94. Mangan, K., May 31, 2011. Nursing schools increasingly turn to part-time faculty. Chron. High. Educ. [online]. Accessed at: http://chronicle.com/article/NursingSchools-Increasingly/127727/?sid¼at&utm_source¼at&utm_medium¼en. Mariani, B.A., Arcamone, A., Cummins, J., 2012. Student and Register Nursing Staff's Perceptions of 12-hour Clinical Rotations in an Undergraduate Baccalaureate Nursing Program. Sigma Theta Tau 41 Biennial Convention. Accessed at: http:// hdl.handle.net/10755/201914. Matheny, R.V., 1969. Pre and post conferences for students. Am. J. Nurs. 69 (2), 286e289. McCabe, B., 1985. The improvement of instruction in the clinical area: a challenge waiting to be met. J. Nurs. Educ. 24 (6), 255e257. Mitchell, C.A., Krainovich, B., 1982. Conducting pre and post conferences. Am. J. Nurs. 82, 823e825. Pardue, K.T., Morgan, P., 2008. Millenials considered: a new generation, new approaches, and implications for nursing education. Nurs. Educ. Perspect. 29 (2), 74e79. Pilcher, J., 2011. Teaching and learning with concept maps. Neonatal Netw. 30 (5), 336e339. http://dx.doi.org/10.1891/0730-0832.30.5.336. Rassool, G.H., Rawaf, S., 2007. Learning style preferences of undergraduate nursing, students. Nurs. Stand. 21 (32), 35e41. Rossignol, M., 2000. Verbal and cognitive activities between and among students and faculty clinical conferences. J. Nurs. Educ. 39 (6), 245e250. Skiba, D.J., Barton, A.J., 2006. Adapting your teaching to accommodate the net generation of learners. Online J. Issues Nurs. (OJIN) 11 (2). http://dx.doi.org/ 10.3912/OJIN.Vol11No02Man04. Manuscript 4. Tanner, C.A., 2006. The next transformation: clinical education. J. Nurs. Educ. 45 (4), 99e100.
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