As you approach the nursing station, a student rushes up, wide-eyed and breathless. "My patient needs a catheter!" You can sense the excitement, anxiety, and fear all at once, as you begin to question the student about the patient context and the student's previous experience with the skill.
If you have ever taught nursing students in the clinical setting, the above scenario is likely familiar. Beginning to apply skills learned in the safety of the laboratory setting is exciting, and working with a "real" patient elevates the excitement to anxiety, sometimes almost fear. When combined with the fact that the student's performance may be evaluated, it is not surprising that students find clinical experiences stress provoking.
Nursing students are not the only ones that find such situations stressful. Clinical instruction of students is a critical component of nursing education programs. However, many instructors have little or no formal preparation in how to teach, much less how to evaluate student performance.1 Although often recognized as clinical experts, clinical instructors report feeling inadequately prepared or supported in their teaching endeavors.2,3 Helping students maximize learning in the clinical setting is different than providing patient care, and the added responsibility to evaluate students is often daunting. Even the most experienced clinical instructors find guiding and evaluating students in the clinical setting to be a challenging, complex process and often struggle with giving feedback or assigning grades.4 BSPOTTED, an innovative teaching strategy developed by the author, will be explored as a way to facilitate evaluation and enhance student learning when performing skills in the clinical setting.
Approach
The acronym BSPOTTED (Basics, Skill, Preparation, Organization, Therapeutic interaction, Teaching, Evaluation, Documentation) provides a quick 8-point framework to maximize learning and reduce the stress for both the student and instructor with respect to the evaluation of performance. In addition, using this framework encourages students to broaden their focus beyond only the psychomotor skill; rather, they are reminded to integrate multiple facets of their prior learning during the performance of the skill. Before beginning a skill requiring the support of their instructor, students are asked to consider the 8 points in the BSPOTTED framework.
Basics. Basics encompasses the fundamental prior learning the student brings to the clinical setting. Ensuring that students consistently perform hand hygiene, introduce themselves, demonstrate proper body mechanics, and engage in ongoing assessment of the patient is essential. Routine activities such as these should not require a reminder, but often do. Students can become so focused on the task at hand, they forget the basics.
Skill. Skill refers to the student's psychomotor ability in performing the steps of the intervention/procedure and is commonly what is at the forefront of the student's mind. Typically, the instructor is with the student to provide guidance and support when performing a new task. Feedback during the completion of the skill should be limited to only that which is essential to safeguard quality care.
Preparation. It is important for the student to have an understanding of the skill (eg, steps and rationale) and the indication for the intervention/procedure. Although students are often excited and ready to rush in and "do," most students would benefit from an opportunity to talk through the steps of the procedure verbally with the instructor in advance. This discussion also serves to help students anticipate patient responses and prepare for potential challenges.1 Determining students' understanding of the indication for the intervention also creates an opportunity to assess and foster their ability for critical thinking about their specific patient.
Organization. Students who are nervous tend to be focused on the task and may lack organization when performing the skill. Organization, in advance and during the performance of the intervention, enhances the care provided. Flagging the importance of organization can help students stop and think about how to set up the interaction. Simply asking "What supplies will you need?" or "Where do you plan to set up your tray?" creates an environment that maximizes student learning and improves the care the patient receives.
Therapeutic interaction. Performing a skill is stressful for students, and they may comment that they need emotional support to get through their first attempt at performing a skill on a patient. While this may be true, it does not preclude the student from providing therapeutic support to the patient. Reminding students in advance and encouraging them throughout the interaction to use therapeutic communication techniques help to establish rapport that benefits both the patient and student during the experience. Including the family should also be expected.
Teaching. Patient education is an essential component of nursing practice but might be forgotten by students when faced with performing a new skill. At a minimum, the student should assess the patient's understanding of the procedure and explain the reason for the procedure and what to expect during it. Students may view teaching as something required only with discharge or a new diagnosis and may need to be reminded to maximize opportunities for teaching every time they walk in the room. Students should be encouraged to recognize teachable moments and provide opportunities for the patient to ask questions.
Evaluation. Students are expected to evaluate the patient response to care with ongoing assessment during and after the intervention. To maximize learning, a brief discussion about the nursing process and reconsideration of goals and priority nursing diagnoses should occur following the interaction. Another element of evaluation is the expectation that students reflect on their performance, as well as receive immediate formative feedback from the instructor. Formalizing this feedback helps to encourage reflection and promotes ongoing learning, both key components of a self-regulating profession.5
Documentation. Once the skill is complete, a sense of relief typically comes over the student. At this point, it may be necessary to remind the student to close the loop by completing the documentation or reporting findings. Ensuring this essential component of safe care is done provides an opportunity for students to concisely summarize their findings and communicate them to the nurse responsible for the patient's care.
Anecdotally, reviewing BSPOTTED with novice students before performing skills has helped to reduce anxiety, improve ability, enrich learning, and enhance care by encouraging the student to perform the skill in the broader context of quality, comprehensive nursing care. Students report feeling more confident after reviewing BSPOTTED as it provides structure and direction for the skill. Instructors and students have reported that BSPOTTED creates clarity of expectations and provides a framework for feedback that makes the evaluation of student performance less subjective and more valuable.
Conclusions
By providing structure for guiding and evaluating students, instructors are better able to encourage the application of new knowledge and integration of prior learning with the performance of skills in the clinical setting. Using a common framework, students and faculty have a consistent approach when preparing for, implementing, and evaluating the interaction; student anxiety is reduced, and confidence is increased. Using BSPOTTED can help students and instructors maximize learning when performing skills in the clinical setting, while integrating multiple facets of prior learning and safeguarding quality patient care.
References