To overcome challenges presented by increasing student enrollment and competition for clinical sites, nursing schools are required to find creative clinical placements, replace clinical with simulation, or create nontraditional clinical activities to educate prelicensure nursing students (National League for Nursing [NLN], 2017; Pesiachovich, 2016). Faculty-supervised patient care has documented shortcomings and has not changed in 30 years yet, by general consensus, remains central to nursing education (Benner, Sutphen, Leonard, Day, & Shulman, 2010; Ironside, McNelis, & Ebright, 2014; McNelis et al., 2014; Pesiachovich, 2016). However, research by McNelis et al. (2014) supported that the traditional model results in missed opportunities for learning and task completion as a measure of learning.
With calls to debrief across the curriculum (NLN, 2015), faculty at our school of nursing expressed a desire to have smaller numbers of students in patient care clinical experiences (PCCE) to focus more time with each student and engage in critical conversations. This article describes how one school of nursing adapted and implemented a strategy, the Two-Minute Assessment (TMA; Caputi, 2010), to allow more time for faculty in clinical teaching to engage in traditional care with each student while allowing other students to have meaningful experiences. The original TMA requires a student to physically assess a patient and environment in two minutes, record the findings, and then complete a concept map for one selected finding. We adapted the TMA by incorporating the most significant component of simulation learning, debriefing (Adamson & Rodgers, 2016), and extending the activity throughout the clinical day.
STRATEGY
As designed by Caputi (2010), the TMA begins with the student performing an assessment of a patient in two minutes, without prior knowledge of the admitting diagnosis or health history. Once the assessment is complete, the student writes down the information obtained and reviews the information with faculty to identify a sign or symptom for the development of a concept map based on the identified symptom. The student develops the concept map to identify the underlying cause of the manifestation and recognize other data to collect. After the activity, Caputi recommends engaging in critical thinking exercises.
Influenced by the debriefing for meaningful learning method (Dreifuerst, 2012), the Two-Minute Assessment With Debriefing (TMAD) extends this activity by providing structured and unstructured debriefing as a critical thinking exercise following the activity. The TMAD incorporates written reflective questions to guide learners to think about their own thinking process during the activity. Questions were designed to develop assimilation, accommodation, and anticipation, all central to debriefing (Dreifuerst, 2009).
Once probable causes of the symptoms are developed, students are guided through a worksheet to anticipate information needed to support the diagnosis. To incorporate assimilation and accommodation, students are asked to identify what information they obtained in the two minutes that "fits" the probable diagnosis and what information does not. Students return to the patient room, complete another assessment with no time restraint, and review the electronic health record (EHR). Students are encouraged during this time to provide traditional care, with the primary nurse and peers. Once this is complete, faculty give students reflective questions focused on realizations that occurred between completing the concept map and the "aha" moments that happened during the second assessment and the retrieval of information from the EHR. Students analyze each assessment they performed and self-reflect through writing. The reflective questions include:
1. What did you do well in your two-minute assessment before knowing the rest of the story? After your first two-minute assessment, what were you thinking about?
2. What would you do differently? What made the situation interesting? What stood out?
3. After developing your concept map, what did you anticipate searching for in the EHR that would confirm or negate the potential disease processes you identified? What disease processes have similar signs and symptoms that you identified in your concept map?
4. What critical findings (assessments, diagnostics, laboratory values, medications) differentiate this disease process from others? What did you learn from this experience?
In postconference, students are asked to discuss the first and second assessments and share reflective statements. Clinical faculty then engage students in more formal debriefing through Socratic questioning (Dreifuerst, 2012).
FACULTY AND STAFF INVOLVEMENT
Faculty are typically assigned a clinical group of 10 students per each rotation. To provide relief to faculty and nursing staff, students are divided into pairs. One student in the pair is assigned the TMAD; the other is assigned to traditional patient care. With a typical assignment of 10 students, five students participate in PCCE and five participate in the TMAD, rotating roles with each subsequent shift. Using originally scheduled, traditional clinical days allows student EHR access without privacy violation.
The actual two-minute assessment is completed within the first 30 minutes of the clinical shift prior to report. The student is released from the clinical unit to create the concept map; the student reports back to faculty after morning medications. This time frame allows clinical faculty to work with five students in traditional care during the busiest portion of the clinical shift. TMAD students are allowed to use resources, including the Internet, to support their findings. Those who finish early are assigned to complete traditional care with their peer for the rest of the shift.
To engage key stakeholders, a series of meetings was held on the scheduled hospital units during staff meetings. The TMAD was explained to nursing staff who would interact with students. These meetings were essential to the implementation of the activity, as students would be present on the hospital units for a short amount of time accessing patient records but not providing direct patient care and would need to access EHRs to complete the requirements.
The meetings included explanation of the detailed assignment, expectations of students and faculty, and the role of the staff. The detailed explanation included how the assignment would be conducted throughout the day and the need for minimal interaction between staff and participating nursing students. Staff were instructed to minimize conversation with students to avoid inadvertently helping them with clinical information before the first part of the assignment was complete. The ideal area for students to complete the TMAD in proximity to faculty was the conference room on the unit.
DISCUSSION
Although the TMAD does not directly decrease the number of students in PCCE, this learning strategy allowed the faculty-to-student ratio in direct PCCE to be reduced to 1:5. The benefits of offsetting students in traditional PCCE include more one-on-one time with students, increased ability for faculty to engage in more conversations with each student, and reduced demand on faculty during peak medication administration times. Faculty also report an ability to focus on student thinking as opposed to task completion.
Students who successfully identified the anticipated findings prior to reassessment and exploring the EHR reported the learning opportunity "let them think like a nurse and begin to see how a nurse should begin to put the clinical picture together." Students are allowed to evaluate the experience at the end of the course and generally report positive comments. Faculty have concluded during postconference that students who complete the nontraditional clinical day are as versed in understanding the care for the patient as students who complete the traditional clinical day. Students involved in direct PCCE and the TMAD have often been observed to collaborate together. Their shared "aha" moments during the clinical day and in debriefing result in a high-energy conversation.
The adaptation of TMAD allows for students to have considerable time to think through patient care. The goals of this activity are to encourage thinking, explore ways to engage students in nontraditional clinical methods, and provide more time in direct PCCE for faculty and students, allowing them to critically think through patient care. Thus, clinical experiences become more of a thinking activity as opposed to "getting the work done as a measure of learning" (McNelis et al., 2014, p. 32). Future research on the TMAD as a clinical teaching and learning strategy that contributes to clinical reasoning is needed, along with other ways to engage students in thinking about the complexities of patient care and supporting faculty in the process.
REFERENCES