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Nursing rounds as a pedagogical strategy: anchoring theory to practice in gerontological nursing
Nurse Education in Practice (2005) 5, 63–69
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
Nursing rounds as a pedagogical strategy: anchoring theory to practice in gerontological nursing J. Perry*, B.L. Paterson1 School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5 Accepted 5 March 2004
KEYWORDS
Summary There is considerable concern among nursing educators that baccalaureate nursing students’ ageist attitudes about the elderly and the lack of understanding of the praxis of nursing care of older adults is not significantly changed by classroom lectures or discussions. Although there is general agreement that working with an experienced practitioner may positively impact on nursing students’ perceptions and knowledge about the nursing care of older adults, the clinical learning experiences in this field are often uneven and problematic. In the paper, the authors present a strategy, an adaptation of traditional bedside rounds, in which students are invited to become members of a learning community in the nursing care of older adults. Based on the theory of situated learning by Lave and Wenger, the strategy entails nursing students’ active involvement with skilled practitioners in the three phases of the strategy, i.e., orientation, adaptation, and integration. The authors describe how the strategy was implemented in one school of nursing. They conclude with an invitation for faculty and practitioners to further refine and assess this strategy. c 2004 Elsevier Ltd. All rights reserved.
Nursing care of older adults; Nursing students; Learning community; Situated learning
Many concepts, such as functional assessment, autonomy, frailty, and communication (Barkay and Tabak, 2002; Markle-Reid and Browne, 2003; Perry et al., 2003), in the nursing care of older adults should be foundational to practice. However, researchers have determined that nursing students’ *
Corresponding author. Tel.: +1-604-822-7496; fax: +1-604822-7466. E-mail addresses: [email protected]; [email protected]. 1 Tel.: +1-604-822-7505; fax: +1-604-822-7466.
integration of these concepts is often lacking (Brown and Draper, 2003; Slevin, 1991; Stevens and Crouch, 1992; Tuohy, 2003). For example, despite lectures about recognizing and assessing delirium, treating pain in the cognitively impaired and cautions about the dosage and side effects of medications, new graduates frequently do not apply the knowledge in their practice as has been identified in other areas (Blomqvist and Hallberg, 2001; Flick and Foreman, 2000; Ludwick and O’Toole, 1996). This may occur in part because more socially based influences, such as ageism, tend to be hidden from
1471-5953/$ - see front matter c 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2004.03.001
64 nursing students’ consciousness and are therefore not accessible to them in their practice (Herdman, 2002; Tuohy, 2003). A related concern is that clinical teaching strategies have remained essentially stagnant in nursing education over the past three decades. These essentially evaluative and didactic approaches have constrained the integration of complex concepts in clinical practice (Paterson, 1994). In addition, such pedagogical approaches have been criticized as promoting unreflective and passive thinking by nursing students (Paterson, 1997). There has been a recent call for new methods of clinical teaching that embrace tenets of new curricular paradigms, such as the need to foster clinical reasoning, collaborative learning, active involvement, and learning communities (Paterson, 1997; Tuohy, 2003). In the following paper, the authors will present a description of a clinical teaching strategy, an innovative variation of bedside teaching rounds that draws on a current theory in adult learning, situated learning. They will discuss their experience with the implementation of this teaching method, including the theoretical and empirical foundations for the use of this strategy, the format and processes involved, the necessary preparation and planning, and the challenges they encountered. The paper will conclude with a discussion of how this strategy may be further adapted to meet the learning needs of nursing students and nurses who provide nursing care for older adults.
Review of literature There is extensive literature that points to the poor quality of interaction between nursing students and older patients (Slevin, 1991; Stevens and Crouch, 1992; Tuohy, 2003). Although the reasons for this are varied, most authors agree that there is a need for new, innovative ways for nursing students to learn the skills and attitudes to provide nursing care to older adults from practitioners in the field. For example, Leblanc (1995) compared the outcomes of a lecture–discussion versus a simulation in improving nursing students’ attitudes toward the elderly. She determined that the outcomes of either strategy were not significant; however, there was a significant change in students’ attitudes following eight weeks of clinical practice that included mentorship by skilled practitioners. Tuohy (2003) found in her study of nursing students’ communication that students needed to reflect on their practice, particularly the dilemmas of practice in the nursing care of older
J. Perry, B.L. Paterson adults, with a skilled practitioner to enact improvements and to gain new learning in the care of older patients. The clinical setting presents many challenges for nursing students to gain new insights about the elderly. The focus on speed and the work of nursing in clinical settings often precludes students’ ability to reflect on their experiences and nurses are often too preoccupied to assist students to reflect on their practice (Meyer, 2002). Many courses about the nursing care of older adults include a one-toone mentoring experience provided by a single practitioner or “buddy nurse”. Such an experience may be “uneven and problematic” (Meyer, 2002, p. 28); nurses may be unskilled as mentors and have little interest in the role (Andrews and Wallis, 1999). In addition, nurses who have no official connection with a course may have difficulty integrating the course content or understanding the student’s needs. Sheffler (1995) maintains that clinical experiences without skilled mentors who offer concepts and knowledge that are central to the nursing care of older adults have little effect on nursing students’ knowledge and attitudes toward the elderly. One strategy that has been used to teach students in the health professions about the praxis of the profession is patient rounds (Eagles et al., 2001). “Rounds” is a term used in the health professions in a variety of ways, most commonly in reference to case-based or topic-based didactic sessions led by a clinical expert and taking place in a classroom or conference room setting (Keller et al., 2001). Rounds, conducted at a patient’s bedside, are common in health professions, such as nursing; however, involvement of the patient or his/her family is not a given and much of the actual teaching that is conducted in these rounds occurs away from the patient, in the hospital hallway or conference room (Manias and Street, 2001; Usatine et al., 1997). The purpose of bedside rounds is most often to hear a student’s assessment of a patient and to question students about related content (Elliot and Hickam, 1993). They have been used, however, to teach specific skills, such as cardiac auscultation and clinical reasoning (Seldak and Doheny, 1998). This strategy is particularly relevant for students who have not yet developed a full range of skills in the area because it provides exemplars of praxis by skilled practitioners and it fosters the integration of theory into practice (Irby, 1994; Seldak and Doheny, 1998; Usatine et al., 1997). There are a number of models of teaching rounds in the health professions. Medicine has maintained a clear preference for case-oriented
Nursing rounds as a pedagogical stratergy discussions that may or may not take place at the patient’s bedside (Harvey and Cope, 2000; Irby, 1994). In such a model, the student presents a succinct summary of a patient’s case and then awaits clarification or questioning from his/her teacher, a physician. The teachers in bedside rounds may also vary. The most common model of bedside teaching rounds uses an expert practitioner as the teacher but the role of this teacher is most often interpreted as the questioner and examiner (Irby, 1994). Key components of the expert practitioner’s role in patient rounds are modeling expertise, coaching, and providing conceptual scaffolding (Weise et al., 2002). Some have suggested that the ideal is achieved when the teacher is a student who receives feedback about his/her presentation from peers (Ciliska et al., 2001; Seldak and Doheny, 1998). Interdisciplinary rounds have been recommended by a few authors (Keller et al., 2001; Newell, 1999) but others point to the traditional power bases that exist between health disciplines to suggest that nurses often assume a passive stance in such rounds (Manias and Street, 2001). Research has identified the outcomes associated with students’ involvement patient rounds as improved teamwork and collaboration (Newell, 1999; Seldak and Doheny, 1998), increased learning and participation in a community of practice (Harvey and Cope, 2000; Irby, 1994; Seldak and Doheny, 1998), increased confidence (Weise et al., 2002), improved presentation and psychomotor skills (Schneiderman, 2001; Weise et al., 2002), improved quality of care given to patients (Irby, 1994; Keller et al., 2001; Newell, 1999), and fewer critical incidents (Keller et al., 2001). The limitations of bedside teaching rounds include that the environment is often noisy and distracting, the patient may be reluctant to reveal information to a group, and teachers have to be highly improvisational in order to cope with the unpredictability of the clinical setting (Manias and Street, 2001; Schneiderman, 2001).
Theoretical foundation The strategy of patient rounds as described in this paper was inspired by the theory of situated learning developed by Lave and Wenger (1991). Learning is viewed in this theory as the process of social participation with others in ‘communities of practice’. In nursing education, this extends beyond mere acquisition of knowledge and encompasses development of the learner’s identity as a
65 nurse. According to Lave and Wenger (1991), a practice-based profession such as nursing has language, symbols, tools, routines, and ways of being and knowing that cannot be readily communicated by classroom teaching of theoretical knowledge or laboratory teaching of psychomotor skills. They believe that the knowledge that underlies nursing needs to be presented to learners in the context in which it is normally practiced; that is, in settings and situations in which it normally occurs. They state that a learner’s participation in communities of practice entails immersion in the “real-world” of the culture of practice. In the theory of situated learning, learning occurs in relationships with others (Smith, 2003) and the educator’s role is to assist both learners and the members of the community of practice to participate in each other’s learning and experience. Mentoring by experienced practitioners is an important aspect of situated learning (Meyer, 2002). Accordingly, nursing students learn the praxis of nursing, including the tacit knowing that is embedded in nurses’ practices (Knight, 2002), not in abstract terms in the classroom, but whenever they are able to participate in communities of practice, or learning communities, with nurses (Cope et al., 2000). Practitioners are viewed as not only experts within the profession, but as artists who are able to paint a picture of the practice of nursing and to assist learners to develop their identity as a nurse. Central to this theoretical perspective is the cooperation and engagement of all members of the community of practice, including students.
A description of the strategy Clinical Rounds were designed as part of a six-week baccalaureate nursing education course, titled “Common Problems in the Nursing Care of the Frail Elderly.” Clinical practice in this course took place in the long term care division of community health units. The course follows students’ learning experiences in medicine, surgery, obstetrics, and pediatrics; generally during the summer of their third year. Because of the number of elderly patients on medical and surgical units, the students have had prior experiences working with older adults, but very little information about the elderly and the process of aging on which to ground their nursing care. The actual bedside rounds in the course was only one of the teaching and assessment strategies incorporated under the umbrella of “Clinical Rounds”; patient rounds occurred after students had completed assigned preparatory reading or
66 audiovisual screening and had received some didactic teaching about the content focus for the rounds. In addition, students were expected to maintain a portfolio of their experiences and learning during the rounds. The strategy of Clinical Rounds incorporated planning and three phases of the learning trajectory as articulated within the theory of situated learning; the orientation, elaboration and integration (DeWeerdt et al., 2002). Firstly, in the orientation component, the course leader made clear the expectations of the learner and the practitioner. In the elaboration component, the learner and the practitioner enter into dialogue with one another about the phenomenon of interest and the learning community is structured in a way that the learner experiences the “interplay between the knowing and doing” (DeWeerdt et al., 2002, p. 31) of the nursing care of older adults. The final component, the integration, occurs when learners are able to apply what they have learned to other contexts and situations; the insights they have gained in the community of practice are integrated into their thinking and doing.
Planning phase Prior to the implementation of the course, Perry, as course leader, and four clinical nurse specialists in gerontology discussed their goals as to the nature of the students’ learning experience and what clinical placements and learning activities would result in these outcomes. Perry also described the student population and their prior learning. To that end, they identified appropriate readings for students, along with study questions to guide students’ learning. For example, to prepare for the topic of communication in dementia care prior to bedside rounds, students were directed to read a chapter in the textbook about the nursing care of older adults and they watched a CD-ROM “From Patient To Person” (Purvis et al., 2000) with the practitioner who was an expert in this area. Topics selection for Clinical Rounds was based on problems or issues that students were likely to have encountered or would likely encounter in relation to working with the older population in various settings, including the person’s home. The topics that have been included over a two-year period include: • Communication in dementia care • Incontinence • Wounds and decubiti care
J. Perry, B.L. Paterson • Transitions • Pain
Orientation phase During the orientation period, Perry, as course leader, reviewed with students how Clinical Rounds would occur and their responsibilities to prepare for, participate in and document their learning in Clinical Rounds. She stressed that nursing students have experience and knowledge to contribute to practitioners and patients and that all participants in a learning community are considered as coexperts (DeWeerdt et al., 2002). In addition, she emphasized that students should be active participants in their learning by identifying what they needed to know. She provided directions for students to answer questions in a brief summary paper where they could identify key concepts and then discuss the application. The following directions were given to the students in the course syllabus: Each Wednesday afternoon you will be making rounds with a Clinical Specialist or a person with expertise in a particular area. These rounds are designed as intensive learning experiences that will often compliment the care you are providing to clients in the community. Meet at each site at the designated time dressed as a professional nurse. Uniforms are not required. Be sure you have your name tag. To make these experiences meaningful and relevant not only for this course but also for your future learning and employment, a set of questions has been designed for each experience. You are expected to address these questions each week as soon as you can after the Clinical Rounds by writing a set of summary notes. The notes should be approximately one typewritten page and you can add to them if your experience in the community provides you with some additional understanding or insight. At the end of the term you will submit these summaries as part of your Clinical Portfolio.
Adaptation phase During the adaptation phase, students attended bedside rounds with a clinical expert in the topic. This occurred immediately following the preparatory didactic teaching. Six students observed an expert practitioner interact with an elderly patient in regard to the specific topic focus of the rounds. After this observation of 20–30 min, students in pairs enacted a similar interaction with other patients. Students were expected to enact the behaviors that the practitioner had emulated. The practitioner was available to suggest patients who would provide this learning experience, as well as to share her expertise and offer feedback about the students’ performance. The students were encouraged to use other staff as resources when
Nursing rounds as a pedagogical stratergy appropriate. For example, during the communication in dementia care rounds students asked nurses in the clinical area about how the patient’s behavior had changed over time. Each student interacted with a minimum of two elderly patients. Students received a list of questions to guide their observations prior to the rounds. For example, prior to rounds about communication in dementia care, the students were asked to reflect on the following: • How do you gather reliable data from a client who has dementia? • What are some of the things you can do to help ensure that the client feels safe and comfortable when he/she is with you? • What are the some important principles of communication when working with clients who have dementia? • How do we make use of the client’s history when he/she has a very advanced dementia? • What do nurses and nurses’ aides say is important for communicating with people who have dementia?
Integration Immediately following the rounds, students met with the practitioner to debrief about the experience and they were given the opportunity to discuss any of the focus questions of which they were uncertain. In addition, the practitioner facilitated a discussion about aspects of the experience that may have been problematic or obscure to students. For example, the practitioner who was an expert in dementia care asked the students what strategies the students had used and their assessment of the effectiveness of those strategies. She asked them, “ How did you know you made contact with this person?” Students contributed their insights and raised practice-relevant questions for the practitioner to consider, particularly in regard to takenfor-granted practices in gerontology. Students were required to write a summary of their learning in each of the Clinical Rounds. Students were told that each summary should include the answers to the focus questions, consideration of the impact of the issues/topic on the elderly patient and his/her family, and a discussion of how nursing care can influence the outcome of the experience for the elderly patient. These summaries were part of the clinical portfolio, submitted at the end of the course and graded by the course leader. In the course syllabus, clinical portfolios were introduced as “part of the assessment and evaluation
67 of your learning in this course.” The contents of the portfolio included a summary for each of the clinical rounds, and a statement of the student’s beliefs about older adults and aging, and three assignments in relation to communication with the elderly, a clinical concept in the nursing care of older adults, and poly-pharmacy.
The benefits and the challenges Student and practitioner feedback about Clinical Rounds has been extremely positive. Students have consistently evaluated this strategy as the most effective in the course. Practitioners have expressed an appreciation for their contact with students, particularly in reminding them of the level of knowledge of students and as a validation of their role as a clinical expert. Staff in the clinical areas stated that they viewed the strategy as promoting the nursing care of older adults as an exciting and evidence-based practice arena in nursing. There was a qualitative difference in students’ papers about the valuing of elderly people that they wrote at the beginning and end of the course. Some of the students directly attributed their new awareness and sensitivity to the benefits of the nursing care of older adults to the Clinical Rounds experience. There were very few criticisms about the strategy; those that occurred were largely in relation to the challenges that we will discuss in the following paragraph. Families did not participate in the Clinical Rounds but we recognize that their involvement would have enhanced the students’ experience. Despite the popularity and benefits of Clinical Rounds as a pedagogical strategy, there were several challenges in its implementation. One major challenge was the time it took it develop and establish. Although the course leader knew many clinical experts in the field, preparation for Clinical Rounds required many hours to coordinate with the their schedules. In some cases, it was necessary for two experts to share responsibility for particular rounds because of time requirements of the rounds and other commitments. During one summer in which many clinical experts were required to attend suddenly scheduled meetings in relation to a labor dispute, there were occasional times in which the scheduled expert was required to be absent from Clinical Rounds. If there was no alternate person to take over, the course leader assumed this role. A third challenge was when patients who were selected for the rounds had to leave the setting or were otherwise unavailable. This occurred for
68 many reasons, such as the unanticipated patient discharge, and patients being asleep, transferred or visiting with friends and family. In the case of Clinical Rounds in relation to wound care, the expert often discovered that the patient’s dressing had been changed and the opportunity to observe the wound was unavailable to students. An interesting occasional occurrence during the communication in dementia care rounds was a patient who had previously been diagnosed with dementia was remarkably coherent on the day of Clinical Rounds. In addition to the preceding challenges, a course leader who wishes to implement the Clinical Rounds strategy should consider the following. Firstly, although someone could be a clinical expert, he or she might have little experience teaching undergraduate students and have difficulty reorienting their teaching styles to nursing students’ needs and experience. An additional issue is that of the time commitment required of clinical experts to conduct the rounds. All the experts involved in Clinical Rounds had a Faculty Associate relationship with the school of nursing. Thus, they were all committed to teaching undergraduate students from the school. All the hospitals at which rounds were conducted were also affiliated with the university and they all were within an easy commuting distance.
Conclusion The use of clinical experts in nursing education has long been recognized as efficacious. Faculty often comment on how students are inspired by particular clinical experts. Most frequently these role models for practice are reserved for supervision of senior students who are about to graduate or for an occasional lecture. The authors have described an alternate role for such experts; that is, as facilitators of Clinical Rounds, an innovative way to teach nursing students about the praxis of the nursing care of older adults. Traditionally, rounds have been used as a teaching strategy for students at senior or practicum levels in their education program, as a forum in which the integration of knowledge into practice is demonstrated to faculty as a prelude to actual practice responsibilities. In this paper, the authors have presented rounds were in a format whereby expert practitioners worked dialogically with nursing students who are were intermediate in their nursing practice. Combining didactic and other pedagogical strategies in the three phases of Clinical Rounds fostered the development of nursing students’ perceptions of
J. Perry, B.L. Paterson themselves as part of a learning community within nursing. It had many positive outcomes in terms of the students’ interest in and value of elders and their care. The gap between theory and practice, the perceived lack of fit between the knowledge as presented in texts and lectures and the knowledge as used at the bedside has a long history of undermining the efficacy of educational undertakings in nursing. While some students are able to envision the utility of theories and concepts and make the leap to practice, others who may learn in a different manner or have a learning styles that demand an immediate and more observable relevance learn the information as requisite to pass exams, write papers and the like, but often struggle with application to practice. Although the focus of this paper has been on the application of Clinical Rounds in the nursing care of older adults, it has relevance in any field of nursing in which theory–practice gaps are evident. Research is needed that further investigates the efficacy of the Clinical Rounds strategy in addressing theory–practice gaps within the profession.
References Andrews M., Wallis, M., 1999. Mentorship in nursing: a literature review. Journal of Advanced Nursing 29 (1), 201–209. Blomqvist K., Hallberg, I.R., 2001. Recognizing pain in older adults living in sheltered accommodation: the views of nurses and older adults. International Journal of Nursing Studies 38 (3), 305–318. Barkay A., Tabak, N., 2002. Elderly residents’ participation and autonomy within a geriatric ward in a public institution. International Journal of Nursing Practice 8, 198–209. Brown A., Draper, P., 2003. Accomodative speech and terms of endearment: elements of a language mode often experienced by older adults. Journal of Advanced Nursing 41 (1), 15–21. Cope P., Cuthbertson P., Stoddart, B., 2000. Situated learning in the practice placement. Journal of Advanced Nursing 31 (4), 850–856. Ciliska D.K., Pinelle J., DiCenso A., Cullum, N., 2001. Resources to enhance evidence-based nursing practice. AACN Clinical Issues 12 (4), 520–528. DeWeerdt S., Corthouts F., Martens H., Bouwen, R., 2002. Developing professional learning environments: model and application. Studies in Continuing Education 24 (1). Eagles J.M., Calder S.A., Nicoll K.S., Walker, L.G., 2001. A comparison of real patients, simulated patients and videotaped interview in teaching medical students about alcohol misuse. Medical Teacher 23 (5), 490–493. Elliot D.L., Hickam, D.H., 1993. Attending rounds on in-patient units: differences between medical and non-medical services. Medical Education 27 (6), 503–508. Flick D., Foreman, M., 2000. Consequences of not recognizing delirium superimposed on dementia in hospitalized elderly individuals. Journal of Gerontological nursing 26 (1), 30–40.
Nursing rounds as a pedagogical stratergy Harvey R.T., Cope, D.W., 2000. Behavioral medicine and teaching rounds: improving doctor–patient interaction skills. Academic Medicine 75, 561. Herdman, E., 2002. Challenging the discourses of nursing ageism. International Journal of Nursing Studies 39 (1), 105–114. Irby, D.M., 1994. Three exemplary models of case-based teaching. Academic Medicine 69 (12), 947–953. Keller C.A., Carolin K., Fedoronko, K., 2001. Leadership and professional development bone marrow transplant teaching rounds: promoting excellence in nursing care. Oncology Nursing 28 (3), 457–458. Knight, P., 2002. A systemic approach to professional development: learning as practice. Teaching and Teacher Education 18, 229–241. Lave J., Wenger, E., 1991. Situated Learning Legitimate Peripheral Participation. University of Cambridge Press, Cambridge. Leblanc, P.A., 1995. Attitudes of nursing students toward the elderly as influenced by lecture–discussion with and without simulation. Unpublished doctoral dissertation, University of Southern Mississippi. Ludwick R., O’Toole, A.W., 1996. The confused patient: nurses’ knowledge and interventions. Journal of Gerontological Nursing 22 (1), 44–49. Manias E., Street, A., 2001. Nurse–doctor interaction during critical care ward rounds. Journal of Clinical Nursing 19 (4), 442–450. Markle-Reid M., Browne, G., 2003. Conceptualization of frailty in relation to older adults. Journal of Advanced Nursing 44 (1), 58–68. Meyer, T., 2002. Novice teacher learning communities: an alternative to one-to-one mentoring. American Secondary Education 31 (1), 27–42. Newell, W.H., 1999. The promise of integrative learning. About Campus 4 (2), 17–23. Paterson, B., 1994. The view from within: perspectives of clinical teachers. International Journal of Nursing Studies 31 (4), 349–360.
69 Paterson, B., 1997. The negotiated order of clinical teaching. Journal of Nursing Education 36, 197–205. Perry, J., Galloway, S., Bottorff, J., Nixon, S., in press. Communicating with people who have dementia and live in nursing homes: improving the odds. Journal of Gerontological Nursing, March 2003. Purvis, B., Perry, J., O’Connor, D., 2000. From patient to person: Changing the lens in dementia care. An Interactive CD ROM for Interdisciplinary learning Information and Technology Services. University of British Columbia. Schneiderman, H., 2001. Cardiac auscultation and teaching rounds: How can cardiac auscultation be resuscitated? Comment Editorial American Journal of Medicine 110 (3), 233–235. Seldak C.A., Doheny, M.O., 1998. Peer review through clinical rounds: a collaborative critical thinking strategy. Nurse Educator 23 (5), 42–45. Sheffler, S.J., 1995. Do clinical experiences affect nursing students’ attitudes toward the elderly. Journal of Nursing Education 34 (7), 312–316. Slevin, O.D.A., 1991. Ageist attitudes among young adults: implications for a caring profession. Journal of Advanced Nursing 16 (10), 1197–1205. Smith, M.K., 2003 ‘Communities of practice’ the encyclopedia of informal education. Available from www.infed.org/biblio/ communities_of_practice.htm. Stevens J.A., Crouch, M., 1992. Working with the elderly: Do students care for it? Australian Journal of Advanced Nursing 9 (3), 12–17. Tuohy, D., 2003. Student nurse–older person communication. Nurse Education Today 2, 19–26. Usatine R.P., Nguyen K., Randall J., Irby, D.M., 1997. Four exemplary preceptors’ strategies for efficient teaching in managed care settings. Academic Medicine 72 (9), 766–769. Weise J., Varosy P., Tierne, L., 2002. Improving oral presentation skills with a reasoning curriculum: a prospective controlled study. Americal Journal of Medicine 112 (3), 212–218.
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
Nursing rounds as a pedagogical strategy: anchoring theory to practice in gerontological nursing J. Perry*, B.L. Paterson1 School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5 Accepted 5 March 2004
KEYWORDS
Summary There is considerable concern among nursing educators that baccalaureate nursing students’ ageist attitudes about the elderly and the lack of understanding of the praxis of nursing care of older adults is not significantly changed by classroom lectures or discussions. Although there is general agreement that working with an experienced practitioner may positively impact on nursing students’ perceptions and knowledge about the nursing care of older adults, the clinical learning experiences in this field are often uneven and problematic. In the paper, the authors present a strategy, an adaptation of traditional bedside rounds, in which students are invited to become members of a learning community in the nursing care of older adults. Based on the theory of situated learning by Lave and Wenger, the strategy entails nursing students’ active involvement with skilled practitioners in the three phases of the strategy, i.e., orientation, adaptation, and integration. The authors describe how the strategy was implemented in one school of nursing. They conclude with an invitation for faculty and practitioners to further refine and assess this strategy. c 2004 Elsevier Ltd. All rights reserved.
Nursing care of older adults; Nursing students; Learning community; Situated learning
Many concepts, such as functional assessment, autonomy, frailty, and communication (Barkay and Tabak, 2002; Markle-Reid and Browne, 2003; Perry et al., 2003), in the nursing care of older adults should be foundational to practice. However, researchers have determined that nursing students’ *
Corresponding author. Tel.: +1-604-822-7496; fax: +1-604822-7466. E-mail addresses: [email protected]; [email protected]. 1 Tel.: +1-604-822-7505; fax: +1-604-822-7466.
integration of these concepts is often lacking (Brown and Draper, 2003; Slevin, 1991; Stevens and Crouch, 1992; Tuohy, 2003). For example, despite lectures about recognizing and assessing delirium, treating pain in the cognitively impaired and cautions about the dosage and side effects of medications, new graduates frequently do not apply the knowledge in their practice as has been identified in other areas (Blomqvist and Hallberg, 2001; Flick and Foreman, 2000; Ludwick and O’Toole, 1996). This may occur in part because more socially based influences, such as ageism, tend to be hidden from
1471-5953/$ - see front matter c 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2004.03.001
64 nursing students’ consciousness and are therefore not accessible to them in their practice (Herdman, 2002; Tuohy, 2003). A related concern is that clinical teaching strategies have remained essentially stagnant in nursing education over the past three decades. These essentially evaluative and didactic approaches have constrained the integration of complex concepts in clinical practice (Paterson, 1994). In addition, such pedagogical approaches have been criticized as promoting unreflective and passive thinking by nursing students (Paterson, 1997). There has been a recent call for new methods of clinical teaching that embrace tenets of new curricular paradigms, such as the need to foster clinical reasoning, collaborative learning, active involvement, and learning communities (Paterson, 1997; Tuohy, 2003). In the following paper, the authors will present a description of a clinical teaching strategy, an innovative variation of bedside teaching rounds that draws on a current theory in adult learning, situated learning. They will discuss their experience with the implementation of this teaching method, including the theoretical and empirical foundations for the use of this strategy, the format and processes involved, the necessary preparation and planning, and the challenges they encountered. The paper will conclude with a discussion of how this strategy may be further adapted to meet the learning needs of nursing students and nurses who provide nursing care for older adults.
Review of literature There is extensive literature that points to the poor quality of interaction between nursing students and older patients (Slevin, 1991; Stevens and Crouch, 1992; Tuohy, 2003). Although the reasons for this are varied, most authors agree that there is a need for new, innovative ways for nursing students to learn the skills and attitudes to provide nursing care to older adults from practitioners in the field. For example, Leblanc (1995) compared the outcomes of a lecture–discussion versus a simulation in improving nursing students’ attitudes toward the elderly. She determined that the outcomes of either strategy were not significant; however, there was a significant change in students’ attitudes following eight weeks of clinical practice that included mentorship by skilled practitioners. Tuohy (2003) found in her study of nursing students’ communication that students needed to reflect on their practice, particularly the dilemmas of practice in the nursing care of older
J. Perry, B.L. Paterson adults, with a skilled practitioner to enact improvements and to gain new learning in the care of older patients. The clinical setting presents many challenges for nursing students to gain new insights about the elderly. The focus on speed and the work of nursing in clinical settings often precludes students’ ability to reflect on their experiences and nurses are often too preoccupied to assist students to reflect on their practice (Meyer, 2002). Many courses about the nursing care of older adults include a one-toone mentoring experience provided by a single practitioner or “buddy nurse”. Such an experience may be “uneven and problematic” (Meyer, 2002, p. 28); nurses may be unskilled as mentors and have little interest in the role (Andrews and Wallis, 1999). In addition, nurses who have no official connection with a course may have difficulty integrating the course content or understanding the student’s needs. Sheffler (1995) maintains that clinical experiences without skilled mentors who offer concepts and knowledge that are central to the nursing care of older adults have little effect on nursing students’ knowledge and attitudes toward the elderly. One strategy that has been used to teach students in the health professions about the praxis of the profession is patient rounds (Eagles et al., 2001). “Rounds” is a term used in the health professions in a variety of ways, most commonly in reference to case-based or topic-based didactic sessions led by a clinical expert and taking place in a classroom or conference room setting (Keller et al., 2001). Rounds, conducted at a patient’s bedside, are common in health professions, such as nursing; however, involvement of the patient or his/her family is not a given and much of the actual teaching that is conducted in these rounds occurs away from the patient, in the hospital hallway or conference room (Manias and Street, 2001; Usatine et al., 1997). The purpose of bedside rounds is most often to hear a student’s assessment of a patient and to question students about related content (Elliot and Hickam, 1993). They have been used, however, to teach specific skills, such as cardiac auscultation and clinical reasoning (Seldak and Doheny, 1998). This strategy is particularly relevant for students who have not yet developed a full range of skills in the area because it provides exemplars of praxis by skilled practitioners and it fosters the integration of theory into practice (Irby, 1994; Seldak and Doheny, 1998; Usatine et al., 1997). There are a number of models of teaching rounds in the health professions. Medicine has maintained a clear preference for case-oriented
Nursing rounds as a pedagogical stratergy discussions that may or may not take place at the patient’s bedside (Harvey and Cope, 2000; Irby, 1994). In such a model, the student presents a succinct summary of a patient’s case and then awaits clarification or questioning from his/her teacher, a physician. The teachers in bedside rounds may also vary. The most common model of bedside teaching rounds uses an expert practitioner as the teacher but the role of this teacher is most often interpreted as the questioner and examiner (Irby, 1994). Key components of the expert practitioner’s role in patient rounds are modeling expertise, coaching, and providing conceptual scaffolding (Weise et al., 2002). Some have suggested that the ideal is achieved when the teacher is a student who receives feedback about his/her presentation from peers (Ciliska et al., 2001; Seldak and Doheny, 1998). Interdisciplinary rounds have been recommended by a few authors (Keller et al., 2001; Newell, 1999) but others point to the traditional power bases that exist between health disciplines to suggest that nurses often assume a passive stance in such rounds (Manias and Street, 2001). Research has identified the outcomes associated with students’ involvement patient rounds as improved teamwork and collaboration (Newell, 1999; Seldak and Doheny, 1998), increased learning and participation in a community of practice (Harvey and Cope, 2000; Irby, 1994; Seldak and Doheny, 1998), increased confidence (Weise et al., 2002), improved presentation and psychomotor skills (Schneiderman, 2001; Weise et al., 2002), improved quality of care given to patients (Irby, 1994; Keller et al., 2001; Newell, 1999), and fewer critical incidents (Keller et al., 2001). The limitations of bedside teaching rounds include that the environment is often noisy and distracting, the patient may be reluctant to reveal information to a group, and teachers have to be highly improvisational in order to cope with the unpredictability of the clinical setting (Manias and Street, 2001; Schneiderman, 2001).
Theoretical foundation The strategy of patient rounds as described in this paper was inspired by the theory of situated learning developed by Lave and Wenger (1991). Learning is viewed in this theory as the process of social participation with others in ‘communities of practice’. In nursing education, this extends beyond mere acquisition of knowledge and encompasses development of the learner’s identity as a
65 nurse. According to Lave and Wenger (1991), a practice-based profession such as nursing has language, symbols, tools, routines, and ways of being and knowing that cannot be readily communicated by classroom teaching of theoretical knowledge or laboratory teaching of psychomotor skills. They believe that the knowledge that underlies nursing needs to be presented to learners in the context in which it is normally practiced; that is, in settings and situations in which it normally occurs. They state that a learner’s participation in communities of practice entails immersion in the “real-world” of the culture of practice. In the theory of situated learning, learning occurs in relationships with others (Smith, 2003) and the educator’s role is to assist both learners and the members of the community of practice to participate in each other’s learning and experience. Mentoring by experienced practitioners is an important aspect of situated learning (Meyer, 2002). Accordingly, nursing students learn the praxis of nursing, including the tacit knowing that is embedded in nurses’ practices (Knight, 2002), not in abstract terms in the classroom, but whenever they are able to participate in communities of practice, or learning communities, with nurses (Cope et al., 2000). Practitioners are viewed as not only experts within the profession, but as artists who are able to paint a picture of the practice of nursing and to assist learners to develop their identity as a nurse. Central to this theoretical perspective is the cooperation and engagement of all members of the community of practice, including students.
A description of the strategy Clinical Rounds were designed as part of a six-week baccalaureate nursing education course, titled “Common Problems in the Nursing Care of the Frail Elderly.” Clinical practice in this course took place in the long term care division of community health units. The course follows students’ learning experiences in medicine, surgery, obstetrics, and pediatrics; generally during the summer of their third year. Because of the number of elderly patients on medical and surgical units, the students have had prior experiences working with older adults, but very little information about the elderly and the process of aging on which to ground their nursing care. The actual bedside rounds in the course was only one of the teaching and assessment strategies incorporated under the umbrella of “Clinical Rounds”; patient rounds occurred after students had completed assigned preparatory reading or
66 audiovisual screening and had received some didactic teaching about the content focus for the rounds. In addition, students were expected to maintain a portfolio of their experiences and learning during the rounds. The strategy of Clinical Rounds incorporated planning and three phases of the learning trajectory as articulated within the theory of situated learning; the orientation, elaboration and integration (DeWeerdt et al., 2002). Firstly, in the orientation component, the course leader made clear the expectations of the learner and the practitioner. In the elaboration component, the learner and the practitioner enter into dialogue with one another about the phenomenon of interest and the learning community is structured in a way that the learner experiences the “interplay between the knowing and doing” (DeWeerdt et al., 2002, p. 31) of the nursing care of older adults. The final component, the integration, occurs when learners are able to apply what they have learned to other contexts and situations; the insights they have gained in the community of practice are integrated into their thinking and doing.
Planning phase Prior to the implementation of the course, Perry, as course leader, and four clinical nurse specialists in gerontology discussed their goals as to the nature of the students’ learning experience and what clinical placements and learning activities would result in these outcomes. Perry also described the student population and their prior learning. To that end, they identified appropriate readings for students, along with study questions to guide students’ learning. For example, to prepare for the topic of communication in dementia care prior to bedside rounds, students were directed to read a chapter in the textbook about the nursing care of older adults and they watched a CD-ROM “From Patient To Person” (Purvis et al., 2000) with the practitioner who was an expert in this area. Topics selection for Clinical Rounds was based on problems or issues that students were likely to have encountered or would likely encounter in relation to working with the older population in various settings, including the person’s home. The topics that have been included over a two-year period include: • Communication in dementia care • Incontinence • Wounds and decubiti care
J. Perry, B.L. Paterson • Transitions • Pain
Orientation phase During the orientation period, Perry, as course leader, reviewed with students how Clinical Rounds would occur and their responsibilities to prepare for, participate in and document their learning in Clinical Rounds. She stressed that nursing students have experience and knowledge to contribute to practitioners and patients and that all participants in a learning community are considered as coexperts (DeWeerdt et al., 2002). In addition, she emphasized that students should be active participants in their learning by identifying what they needed to know. She provided directions for students to answer questions in a brief summary paper where they could identify key concepts and then discuss the application. The following directions were given to the students in the course syllabus: Each Wednesday afternoon you will be making rounds with a Clinical Specialist or a person with expertise in a particular area. These rounds are designed as intensive learning experiences that will often compliment the care you are providing to clients in the community. Meet at each site at the designated time dressed as a professional nurse. Uniforms are not required. Be sure you have your name tag. To make these experiences meaningful and relevant not only for this course but also for your future learning and employment, a set of questions has been designed for each experience. You are expected to address these questions each week as soon as you can after the Clinical Rounds by writing a set of summary notes. The notes should be approximately one typewritten page and you can add to them if your experience in the community provides you with some additional understanding or insight. At the end of the term you will submit these summaries as part of your Clinical Portfolio.
Adaptation phase During the adaptation phase, students attended bedside rounds with a clinical expert in the topic. This occurred immediately following the preparatory didactic teaching. Six students observed an expert practitioner interact with an elderly patient in regard to the specific topic focus of the rounds. After this observation of 20–30 min, students in pairs enacted a similar interaction with other patients. Students were expected to enact the behaviors that the practitioner had emulated. The practitioner was available to suggest patients who would provide this learning experience, as well as to share her expertise and offer feedback about the students’ performance. The students were encouraged to use other staff as resources when
Nursing rounds as a pedagogical stratergy appropriate. For example, during the communication in dementia care rounds students asked nurses in the clinical area about how the patient’s behavior had changed over time. Each student interacted with a minimum of two elderly patients. Students received a list of questions to guide their observations prior to the rounds. For example, prior to rounds about communication in dementia care, the students were asked to reflect on the following: • How do you gather reliable data from a client who has dementia? • What are some of the things you can do to help ensure that the client feels safe and comfortable when he/she is with you? • What are the some important principles of communication when working with clients who have dementia? • How do we make use of the client’s history when he/she has a very advanced dementia? • What do nurses and nurses’ aides say is important for communicating with people who have dementia?
Integration Immediately following the rounds, students met with the practitioner to debrief about the experience and they were given the opportunity to discuss any of the focus questions of which they were uncertain. In addition, the practitioner facilitated a discussion about aspects of the experience that may have been problematic or obscure to students. For example, the practitioner who was an expert in dementia care asked the students what strategies the students had used and their assessment of the effectiveness of those strategies. She asked them, “ How did you know you made contact with this person?” Students contributed their insights and raised practice-relevant questions for the practitioner to consider, particularly in regard to takenfor-granted practices in gerontology. Students were required to write a summary of their learning in each of the Clinical Rounds. Students were told that each summary should include the answers to the focus questions, consideration of the impact of the issues/topic on the elderly patient and his/her family, and a discussion of how nursing care can influence the outcome of the experience for the elderly patient. These summaries were part of the clinical portfolio, submitted at the end of the course and graded by the course leader. In the course syllabus, clinical portfolios were introduced as “part of the assessment and evaluation
67 of your learning in this course.” The contents of the portfolio included a summary for each of the clinical rounds, and a statement of the student’s beliefs about older adults and aging, and three assignments in relation to communication with the elderly, a clinical concept in the nursing care of older adults, and poly-pharmacy.
The benefits and the challenges Student and practitioner feedback about Clinical Rounds has been extremely positive. Students have consistently evaluated this strategy as the most effective in the course. Practitioners have expressed an appreciation for their contact with students, particularly in reminding them of the level of knowledge of students and as a validation of their role as a clinical expert. Staff in the clinical areas stated that they viewed the strategy as promoting the nursing care of older adults as an exciting and evidence-based practice arena in nursing. There was a qualitative difference in students’ papers about the valuing of elderly people that they wrote at the beginning and end of the course. Some of the students directly attributed their new awareness and sensitivity to the benefits of the nursing care of older adults to the Clinical Rounds experience. There were very few criticisms about the strategy; those that occurred were largely in relation to the challenges that we will discuss in the following paragraph. Families did not participate in the Clinical Rounds but we recognize that their involvement would have enhanced the students’ experience. Despite the popularity and benefits of Clinical Rounds as a pedagogical strategy, there were several challenges in its implementation. One major challenge was the time it took it develop and establish. Although the course leader knew many clinical experts in the field, preparation for Clinical Rounds required many hours to coordinate with the their schedules. In some cases, it was necessary for two experts to share responsibility for particular rounds because of time requirements of the rounds and other commitments. During one summer in which many clinical experts were required to attend suddenly scheduled meetings in relation to a labor dispute, there were occasional times in which the scheduled expert was required to be absent from Clinical Rounds. If there was no alternate person to take over, the course leader assumed this role. A third challenge was when patients who were selected for the rounds had to leave the setting or were otherwise unavailable. This occurred for
68 many reasons, such as the unanticipated patient discharge, and patients being asleep, transferred or visiting with friends and family. In the case of Clinical Rounds in relation to wound care, the expert often discovered that the patient’s dressing had been changed and the opportunity to observe the wound was unavailable to students. An interesting occasional occurrence during the communication in dementia care rounds was a patient who had previously been diagnosed with dementia was remarkably coherent on the day of Clinical Rounds. In addition to the preceding challenges, a course leader who wishes to implement the Clinical Rounds strategy should consider the following. Firstly, although someone could be a clinical expert, he or she might have little experience teaching undergraduate students and have difficulty reorienting their teaching styles to nursing students’ needs and experience. An additional issue is that of the time commitment required of clinical experts to conduct the rounds. All the experts involved in Clinical Rounds had a Faculty Associate relationship with the school of nursing. Thus, they were all committed to teaching undergraduate students from the school. All the hospitals at which rounds were conducted were also affiliated with the university and they all were within an easy commuting distance.
Conclusion The use of clinical experts in nursing education has long been recognized as efficacious. Faculty often comment on how students are inspired by particular clinical experts. Most frequently these role models for practice are reserved for supervision of senior students who are about to graduate or for an occasional lecture. The authors have described an alternate role for such experts; that is, as facilitators of Clinical Rounds, an innovative way to teach nursing students about the praxis of the nursing care of older adults. Traditionally, rounds have been used as a teaching strategy for students at senior or practicum levels in their education program, as a forum in which the integration of knowledge into practice is demonstrated to faculty as a prelude to actual practice responsibilities. In this paper, the authors have presented rounds were in a format whereby expert practitioners worked dialogically with nursing students who are were intermediate in their nursing practice. Combining didactic and other pedagogical strategies in the three phases of Clinical Rounds fostered the development of nursing students’ perceptions of
J. Perry, B.L. Paterson themselves as part of a learning community within nursing. It had many positive outcomes in terms of the students’ interest in and value of elders and their care. The gap between theory and practice, the perceived lack of fit between the knowledge as presented in texts and lectures and the knowledge as used at the bedside has a long history of undermining the efficacy of educational undertakings in nursing. While some students are able to envision the utility of theories and concepts and make the leap to practice, others who may learn in a different manner or have a learning styles that demand an immediate and more observable relevance learn the information as requisite to pass exams, write papers and the like, but often struggle with application to practice. Although the focus of this paper has been on the application of Clinical Rounds in the nursing care of older adults, it has relevance in any field of nursing in which theory–practice gaps are evident. Research is needed that further investigates the efficacy of the Clinical Rounds strategy in addressing theory–practice gaps within the profession.
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