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Utilization of nursing home residents for development of assessment skills
Teaching and Learning in Nursing (2015) 10, 128–131
www.jtln.org
Utilization of nursing home residents for development of assessment skills Sheryl K. House DNP, RN, CNS⁎, Mary Ann Goetz MS, RN, CFNP, Susan Dowell MSN, MBA, RNC Ohio University Zanesville, Zanesville, OH 43701, USA KEYWORDS: Assessment; Nursing home; Clinical; Student perceptions
Abstract Acquiring strong assessment skills is imperative for nursing students in order to enhance their learning experiences and future nursing practice. Nursing homes offer a quality clinical experience exposing students to residents experiencing multiple chronic diseases with various levels of physical and cognitive functioning in a slower paced environment. Students' perceptions validated that the nursing home setting provided an effective clinical environment for the development of assessment skills. © 2015 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
1. Introduction The purpose of this article is to discuss how nursing homes can provide meaningful learning opportunities for the nursing student who is developing assessment skills. Assessment is the cornerstone of nursing practice that impacts clinical decision making and nursing interventions. A survey, completed by newly graduated nurses about their most recent work day, identified performing a focused assessment as the third most frequent activity completed (National Council of State Boards of Nursing, 2012). Acquiring strong assessment skills is imperative for nursing students in order to enhance their learning experiences and future nursing practice. Introduction to assessment skills typically occurs in the classroom and laboratory settings. Clinical experiences offer students an opportunity to develop their assessment skills. Exposing students to individuals across the lifespan with varying degrees of health and wellness through diverse clinical ⁎ Corresponding author. Tel.: +1 740 588 2553, +1 740 704 0131 (mobile). E-mail addresses: [email protected] (S.K. House), [email protected] (M.A. Goetz), [email protected] (S. Dowell)
experiences assists students to refine their assessment skills. However, securing clinical opportunities for prelicensed nursing students has become increasingly difficult for nursing programs across the United States. Utilization of clinical placement outside of the acute care settings has become essential for most nursing programs. Nursing homes offer a quality clinical experience for nursing students. Students are exposed to residents experiencing multiple chronic diseases with various levels of physical and cognitive functioning in a slower paced environment. It also provides repeated exposure to residents over a period of time. In 2011, there were 15,683 nursing homes in the United States with 1,388,000 certified Medicare and/or Medicaid beds occupied (Centers for Medicare & Medicaid Services, 2012). The majority (78.3%) of the residents experienced one or more impairments related to their activities of daily living. Moderate to severe cognitive impairment was noted in 64.8% of the residents. The National Nursing Home Survey 2004 noted that circulatory system diseases were the leading primary diagnoses among residents at admission followed by mental disorders then nervous system disorders (Jones, Dwyer, Bercovitz, & Strahan, 2009).
http://dx.doi.org/10.1016/j.teln.2015.01.005 1557-3087/© 2015 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Utilization of nursing home residents The purpose of utilizing the nursing home setting for clinical is to provide the beginning student with the opportunity to acquire hands-on experience and competence in the skills taught during lecture and practiced in the campus laboratory. It is the belief of the faculty that the nursing home setting provides an environment that is conducive to accomplishing the clinical objectives. It provides a setting that allows beginning students to work with a focused population that has various and often complex conditions. These opportunities expose students to multiple experiences that allow them to develop and strengthen their assessment skills.
2. Literature Review Physical assessment skills are essential in nursing practice. The American Nurses Association (2010) has identified assessment as a practice standard for nursing. Nursing literature related to teaching physical assessment skills in the clinical setting for undergraduate students is limited. Giddens and Eddy (2009) conducted research to determine how assessment content was being taught among undergraduate programs. Students conducting assessments on one another in the laboratory setting was reported by all the respondents, making it the most common teaching approach utilized. Other approaches included computer simulation and manikins. A study was conducted to investigate the health assessment teaching modalities of high-fidelity simulation, simulated patients, and community volunteers on self-efficacy and student satisfaction (Luctkar-Flude, Wilson-Keates, & Larocque, 2012). The results demonstrated that each of the learning modalities assisted students in being somewhat confident with their assessment skills. In addition, the students reported satisfaction with all three learning modalities. Another study found that utilization of standardized patients in the laboratory setting instead of a peer, assisted students to score significantly better on an objective structured clinical examination that evaluated health history taking skills, infection control measures, and physical assessment competencies (Bornais, Raiger, Krahn, & El-Marsi, 2012). Nursing homes can be an option to teach physical assessment skills. A survey of 53 nursing schools identified learning nursing skills as an advantage for utilizing nursing homes for clinical placement (Chen, Brown, Groves, & Spezia, 2007). The nursing skills identified as being best taught in the nursing home environment included comprehensive physical assessment and assessment of signs and symptoms of common geriatric illnesses. Mullenbach and Burggraf (2012) noted a significant improvement in student perception of being prepared to perform a history/assessment in the nursing home setting after a nursing home clinical experience. They also noted positive student comments in their personal journal entries related to increased opportunities to interact with residents and practice skills such as physical assessments.
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3. Background The teaching and implementation of assessment skills were taught in a nursing foundations and assessment course. This course was a requirement for the associate degree nursing students in their first semester of the program. One third of the course content focused on assessment. The course content was delivered utilizing the classroom, laboratory, and clinical settings. The faculty strategized how to coordinate the class, campus laboratory, and clinical experience to provide the novice, first semester, associate degree nurse with a meaningful learning experience. The goal by the end of the semester was to have each student possess the skills to obtain a health history, perform a basic head-to-toe assessment and document his or her findings accurately on one resident in the nursing home facility. The clinical hours for the course were divided equally between campus laboratory and the clinical facility. The campus laboratory hours were taught in the nursing laboratory on the university campus. The clinical hours were completed in a nursing home facility. The clinical/ laboratory schedule was developed so that the information and skills that were presented and practiced in campus laboratory in one week could be implemented in the clinical setting the following week. Therefore, the campus laboratory alternated with the clinical experience each week throughout the semester. Assessment content was initially presented to students in the classroom setting. The content was revisited in the campus laboratory setting where students were able to practice their assessment skills related to the content presented in the classroom. Students attended clinical at the nursing home where they were able to implement the assessment skills learned in the classroom and laboratory setting on residents at the facilities. Content delivery began with therapeutic communication, how to conduct an interview and obtain a health history, progressing through assessment of each body system, and finishing with putting it all together in a head-to-toe assessment. During campus laboratory, videos and/or laboratory instructor demonstrations were utilized to assist students in acquiring assessment skills. The students had an opportunity to practice the skills on a peer and document the findings on a health assessment form that was reviewed by the clinical instructor. Students were required to change partners throughout the laboratory experience to increase the variation in their experiences. In addition, they performed assessments on high-fidelity and low-fidelity simulators that were programmed with normal and abnormal assessment sounds. In the nursing home setting, the students were required to apply what they had learned in the previous campus laboratory while assessing their assigned resident. The nursing home facilities provided residents who were mainly older adults with multiple chronic diseases, cognitive and physical impairments, and sensory alterations. Students were assigned a different
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resident each time they were at the clinical facility, providing the student with the opportunity to assess multiple residents with a variety of normal and abnormal assessment findings. The clinical instructor was available at the nursing home to assist and reinforce the assessment skills being performed by the student. Written documentation of the assessment findings was required to be submitted as a postclinical assignment. The clinical instructor reviewed the documentation and provided the student with constructive feedback to enhance their future documentation.
4. Student Perceptions A survey was administered to 36 students to evaluate their clinical experience at the nursing home. As part of the survey, students were asked to discuss how they felt the nursing home environment assisted them in the development of their assessment skills. The responses validated that the students were achieving and accomplishing the desired clinical goals established by faculty. It was also noted that there were even more benefits to utilizing this clinical setting identified by students than initially expected by the faculty. The following are themes and statements synthesized from the students' responses. The most frequently noted theme, which was expected by the faculty, was that the students believed that the nursing home setting offered a variety of residents who had a variety of conditions. The students discussed that, throughout the clinical experience, they were exposed to different assessment findings, both normal and abnormal, that they were able to see, feel, and hear first hand. Many reiterated that the opportunities to experience hands-on the findings that were taught and discussed in class, laboratory, or seen in a book provided them the knowledge and confidence they needed as beginning students. With that confidence, they “would know what to look for in the future.” A few other students added that geriatric patients were challenging thereby giving them a good experience. The descriptions of challenging included “diminished and hard to hear heart/lung sounds”; “different conditions and medical equipment that I had to work around”; and challenging because they had never worked with this population of individuals before and they were uncomfortable at first. The next most frequently discussed benefit was a combination of experience of working on “real people” with repeat opportunities to practice the same skill with the same population over and over again. One student wrote, It helped me with my assessment skills in that we got to repeat the tasks over-and-over again. Each week we went to the nursing home making it a habit to do (assessments) every time we were there. The skills became very familiar and we were able to form patterns of how to do things.
They discussed that this not only allowed for better assessment skills, but also improved communication skills and gave them confidence in interacting with residents one
on one. One student added comments that the nursing home provided repetition and the ability to see different residents/ conditions each week, which made it easier to not only compare assessment findings but also medications, restorative programs, and therapies. As a beginning student, the clinical experience was set up so that the students were exposed to experiencing direct patient care and managing the residents' health care needs. As a result, the students discussed how this type of care added to their experience and allowed for them to better incorporate assessment into the care. One student commented that during the bath they were able to complete their head-to-toe assessment on the resident. Other students felt that the environment was conducive to learning because the staff was very friendly and willing to assist and answer questions. In addition, the residents were cooperative and, generally, were pleased to have the students work with them and complete assessments on them. In fact, it was frequently stated that the residents were actually excited to see the students and enjoyed the extra attention. One student wrote, “they (the residents) didn't mind the extra time to perform our tasks. In the hospital setting, patients are more apt to want you in and out. They don’t feel good and don’t want bothered.” A frequent theme throughout the comments was that the slower pace of the nursing home was beneficial for the beginning student and led them to feeling more at ease, which enhanced their learning experience. This allowed them to discuss and obtain history from the residents, complete full head-to-toe assessments, and improve their comfort level in working with residents in general.
5. Conclusion The nursing home setting provided an effective clinical environment for the development of assessment skills among novice first semester associate degree nursing students. The experience assisted students in developing their communication and assessment skills. Students' perceptions of their experiences supported that nursing homes provided meaningful learning opportunities in these areas. Nursing faculty should consider nursing homes as an environment for clinical placement, especially clinical experiences that focus on the development of assessment skills.
References American Nurses Association (2010). Nursing: Scope and standards of practice (2nd ev.). Silver Spring, MD: American Nurses Association. Bornais, J. A. K., Raiger, J. E., Krahn, R. E., & El-Marsi, M. M. (2012). Evaluating undergraduate nursing students’ learning using standardized patients. Journal of Professional Nursing, 28(5), 291−296. Centers for Medicare & Medicaid Services. (2012). Nursing home data compendium 2012 edition.
Utilization of nursing home residents Chen, S., Brown, J. W., Groves, M. L., & Spezia, A. M. (2007). Baccalaureate education and American nursing homes: A survey of nursing schools. Nurse Education Today, 27, 909−914. Giddens, J. F., & Eddy, L. (2009). A survey of physical examination skills taught in undergraduate nursing programs: Are we teaching too much? Journal of Nursing Education, 48(1), 24−29. Jones, A. L., Dwyer, L. L., Bercovitz, A. R., & Strahan, G. W. (2009). The national nursing home survey: 2004 Overview. Vital and Health Statistics, 13(167), 1−155.
131 Luctkar-Flude, M., Wilson-Keates, B., & Larocque, M. (2012). Evaluating high-fidelity human simulators and standardized patients in an undergraduate nursing health assessment course. Nurse Education Today, 32(4), 448−452. Mullenbach, K. F., & Burggraf, V. (2012). A dedicated learning unit in long-term care: A clinical immersion for student nurses. Geriatric Nursing, 33(1), 63−67. National Council of State Boards of Nursing. (2012). 2011 RN practice analysis: Linking the NCLEX-RN examination to practice, 53, 1−177.
www.jtln.org
Utilization of nursing home residents for development of assessment skills Sheryl K. House DNP, RN, CNS⁎, Mary Ann Goetz MS, RN, CFNP, Susan Dowell MSN, MBA, RNC Ohio University Zanesville, Zanesville, OH 43701, USA KEYWORDS: Assessment; Nursing home; Clinical; Student perceptions
Abstract Acquiring strong assessment skills is imperative for nursing students in order to enhance their learning experiences and future nursing practice. Nursing homes offer a quality clinical experience exposing students to residents experiencing multiple chronic diseases with various levels of physical and cognitive functioning in a slower paced environment. Students' perceptions validated that the nursing home setting provided an effective clinical environment for the development of assessment skills. © 2015 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
1. Introduction The purpose of this article is to discuss how nursing homes can provide meaningful learning opportunities for the nursing student who is developing assessment skills. Assessment is the cornerstone of nursing practice that impacts clinical decision making and nursing interventions. A survey, completed by newly graduated nurses about their most recent work day, identified performing a focused assessment as the third most frequent activity completed (National Council of State Boards of Nursing, 2012). Acquiring strong assessment skills is imperative for nursing students in order to enhance their learning experiences and future nursing practice. Introduction to assessment skills typically occurs in the classroom and laboratory settings. Clinical experiences offer students an opportunity to develop their assessment skills. Exposing students to individuals across the lifespan with varying degrees of health and wellness through diverse clinical ⁎ Corresponding author. Tel.: +1 740 588 2553, +1 740 704 0131 (mobile). E-mail addresses: [email protected] (S.K. House), [email protected] (M.A. Goetz), [email protected] (S. Dowell)
experiences assists students to refine their assessment skills. However, securing clinical opportunities for prelicensed nursing students has become increasingly difficult for nursing programs across the United States. Utilization of clinical placement outside of the acute care settings has become essential for most nursing programs. Nursing homes offer a quality clinical experience for nursing students. Students are exposed to residents experiencing multiple chronic diseases with various levels of physical and cognitive functioning in a slower paced environment. It also provides repeated exposure to residents over a period of time. In 2011, there were 15,683 nursing homes in the United States with 1,388,000 certified Medicare and/or Medicaid beds occupied (Centers for Medicare & Medicaid Services, 2012). The majority (78.3%) of the residents experienced one or more impairments related to their activities of daily living. Moderate to severe cognitive impairment was noted in 64.8% of the residents. The National Nursing Home Survey 2004 noted that circulatory system diseases were the leading primary diagnoses among residents at admission followed by mental disorders then nervous system disorders (Jones, Dwyer, Bercovitz, & Strahan, 2009).
http://dx.doi.org/10.1016/j.teln.2015.01.005 1557-3087/© 2015 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Utilization of nursing home residents The purpose of utilizing the nursing home setting for clinical is to provide the beginning student with the opportunity to acquire hands-on experience and competence in the skills taught during lecture and practiced in the campus laboratory. It is the belief of the faculty that the nursing home setting provides an environment that is conducive to accomplishing the clinical objectives. It provides a setting that allows beginning students to work with a focused population that has various and often complex conditions. These opportunities expose students to multiple experiences that allow them to develop and strengthen their assessment skills.
2. Literature Review Physical assessment skills are essential in nursing practice. The American Nurses Association (2010) has identified assessment as a practice standard for nursing. Nursing literature related to teaching physical assessment skills in the clinical setting for undergraduate students is limited. Giddens and Eddy (2009) conducted research to determine how assessment content was being taught among undergraduate programs. Students conducting assessments on one another in the laboratory setting was reported by all the respondents, making it the most common teaching approach utilized. Other approaches included computer simulation and manikins. A study was conducted to investigate the health assessment teaching modalities of high-fidelity simulation, simulated patients, and community volunteers on self-efficacy and student satisfaction (Luctkar-Flude, Wilson-Keates, & Larocque, 2012). The results demonstrated that each of the learning modalities assisted students in being somewhat confident with their assessment skills. In addition, the students reported satisfaction with all three learning modalities. Another study found that utilization of standardized patients in the laboratory setting instead of a peer, assisted students to score significantly better on an objective structured clinical examination that evaluated health history taking skills, infection control measures, and physical assessment competencies (Bornais, Raiger, Krahn, & El-Marsi, 2012). Nursing homes can be an option to teach physical assessment skills. A survey of 53 nursing schools identified learning nursing skills as an advantage for utilizing nursing homes for clinical placement (Chen, Brown, Groves, & Spezia, 2007). The nursing skills identified as being best taught in the nursing home environment included comprehensive physical assessment and assessment of signs and symptoms of common geriatric illnesses. Mullenbach and Burggraf (2012) noted a significant improvement in student perception of being prepared to perform a history/assessment in the nursing home setting after a nursing home clinical experience. They also noted positive student comments in their personal journal entries related to increased opportunities to interact with residents and practice skills such as physical assessments.
129
3. Background The teaching and implementation of assessment skills were taught in a nursing foundations and assessment course. This course was a requirement for the associate degree nursing students in their first semester of the program. One third of the course content focused on assessment. The course content was delivered utilizing the classroom, laboratory, and clinical settings. The faculty strategized how to coordinate the class, campus laboratory, and clinical experience to provide the novice, first semester, associate degree nurse with a meaningful learning experience. The goal by the end of the semester was to have each student possess the skills to obtain a health history, perform a basic head-to-toe assessment and document his or her findings accurately on one resident in the nursing home facility. The clinical hours for the course were divided equally between campus laboratory and the clinical facility. The campus laboratory hours were taught in the nursing laboratory on the university campus. The clinical hours were completed in a nursing home facility. The clinical/ laboratory schedule was developed so that the information and skills that were presented and practiced in campus laboratory in one week could be implemented in the clinical setting the following week. Therefore, the campus laboratory alternated with the clinical experience each week throughout the semester. Assessment content was initially presented to students in the classroom setting. The content was revisited in the campus laboratory setting where students were able to practice their assessment skills related to the content presented in the classroom. Students attended clinical at the nursing home where they were able to implement the assessment skills learned in the classroom and laboratory setting on residents at the facilities. Content delivery began with therapeutic communication, how to conduct an interview and obtain a health history, progressing through assessment of each body system, and finishing with putting it all together in a head-to-toe assessment. During campus laboratory, videos and/or laboratory instructor demonstrations were utilized to assist students in acquiring assessment skills. The students had an opportunity to practice the skills on a peer and document the findings on a health assessment form that was reviewed by the clinical instructor. Students were required to change partners throughout the laboratory experience to increase the variation in their experiences. In addition, they performed assessments on high-fidelity and low-fidelity simulators that were programmed with normal and abnormal assessment sounds. In the nursing home setting, the students were required to apply what they had learned in the previous campus laboratory while assessing their assigned resident. The nursing home facilities provided residents who were mainly older adults with multiple chronic diseases, cognitive and physical impairments, and sensory alterations. Students were assigned a different
130
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resident each time they were at the clinical facility, providing the student with the opportunity to assess multiple residents with a variety of normal and abnormal assessment findings. The clinical instructor was available at the nursing home to assist and reinforce the assessment skills being performed by the student. Written documentation of the assessment findings was required to be submitted as a postclinical assignment. The clinical instructor reviewed the documentation and provided the student with constructive feedback to enhance their future documentation.
4. Student Perceptions A survey was administered to 36 students to evaluate their clinical experience at the nursing home. As part of the survey, students were asked to discuss how they felt the nursing home environment assisted them in the development of their assessment skills. The responses validated that the students were achieving and accomplishing the desired clinical goals established by faculty. It was also noted that there were even more benefits to utilizing this clinical setting identified by students than initially expected by the faculty. The following are themes and statements synthesized from the students' responses. The most frequently noted theme, which was expected by the faculty, was that the students believed that the nursing home setting offered a variety of residents who had a variety of conditions. The students discussed that, throughout the clinical experience, they were exposed to different assessment findings, both normal and abnormal, that they were able to see, feel, and hear first hand. Many reiterated that the opportunities to experience hands-on the findings that were taught and discussed in class, laboratory, or seen in a book provided them the knowledge and confidence they needed as beginning students. With that confidence, they “would know what to look for in the future.” A few other students added that geriatric patients were challenging thereby giving them a good experience. The descriptions of challenging included “diminished and hard to hear heart/lung sounds”; “different conditions and medical equipment that I had to work around”; and challenging because they had never worked with this population of individuals before and they were uncomfortable at first. The next most frequently discussed benefit was a combination of experience of working on “real people” with repeat opportunities to practice the same skill with the same population over and over again. One student wrote, It helped me with my assessment skills in that we got to repeat the tasks over-and-over again. Each week we went to the nursing home making it a habit to do (assessments) every time we were there. The skills became very familiar and we were able to form patterns of how to do things.
They discussed that this not only allowed for better assessment skills, but also improved communication skills and gave them confidence in interacting with residents one
on one. One student added comments that the nursing home provided repetition and the ability to see different residents/ conditions each week, which made it easier to not only compare assessment findings but also medications, restorative programs, and therapies. As a beginning student, the clinical experience was set up so that the students were exposed to experiencing direct patient care and managing the residents' health care needs. As a result, the students discussed how this type of care added to their experience and allowed for them to better incorporate assessment into the care. One student commented that during the bath they were able to complete their head-to-toe assessment on the resident. Other students felt that the environment was conducive to learning because the staff was very friendly and willing to assist and answer questions. In addition, the residents were cooperative and, generally, were pleased to have the students work with them and complete assessments on them. In fact, it was frequently stated that the residents were actually excited to see the students and enjoyed the extra attention. One student wrote, “they (the residents) didn't mind the extra time to perform our tasks. In the hospital setting, patients are more apt to want you in and out. They don’t feel good and don’t want bothered.” A frequent theme throughout the comments was that the slower pace of the nursing home was beneficial for the beginning student and led them to feeling more at ease, which enhanced their learning experience. This allowed them to discuss and obtain history from the residents, complete full head-to-toe assessments, and improve their comfort level in working with residents in general.
5. Conclusion The nursing home setting provided an effective clinical environment for the development of assessment skills among novice first semester associate degree nursing students. The experience assisted students in developing their communication and assessment skills. Students' perceptions of their experiences supported that nursing homes provided meaningful learning opportunities in these areas. Nursing faculty should consider nursing homes as an environment for clinical placement, especially clinical experiences that focus on the development of assessment skills.
References American Nurses Association (2010). Nursing: Scope and standards of practice (2nd ev.). Silver Spring, MD: American Nurses Association. Bornais, J. A. K., Raiger, J. E., Krahn, R. E., & El-Marsi, M. M. (2012). Evaluating undergraduate nursing students’ learning using standardized patients. Journal of Professional Nursing, 28(5), 291−296. Centers for Medicare & Medicaid Services. (2012). Nursing home data compendium 2012 edition.
Utilization of nursing home residents Chen, S., Brown, J. W., Groves, M. L., & Spezia, A. M. (2007). Baccalaureate education and American nursing homes: A survey of nursing schools. Nurse Education Today, 27, 909−914. Giddens, J. F., & Eddy, L. (2009). A survey of physical examination skills taught in undergraduate nursing programs: Are we teaching too much? Journal of Nursing Education, 48(1), 24−29. Jones, A. L., Dwyer, L. L., Bercovitz, A. R., & Strahan, G. W. (2009). The national nursing home survey: 2004 Overview. Vital and Health Statistics, 13(167), 1−155.
131 Luctkar-Flude, M., Wilson-Keates, B., & Larocque, M. (2012). Evaluating high-fidelity human simulators and standardized patients in an undergraduate nursing health assessment course. Nurse Education Today, 32(4), 448−452. Mullenbach, K. F., & Burggraf, V. (2012). A dedicated learning unit in long-term care: A clinical immersion for student nurses. Geriatric Nursing, 33(1), 63−67. National Council of State Boards of Nursing. (2012). 2011 RN practice analysis: Linking the NCLEX-RN examination to practice, 53, 1−177.