Nurse Educator's Guide to Best Teaching Practice

Nurse Educator’s Guide to Best Teaching Practice

A Case-Based Approach

Keeley C. Harmon Joe Ann Clark Je ery M. Dyck Vicki Moran

123 Nurse Educator’s Guide to Best Teaching Practice

Keeley C. Harmon • Joe Ann Clark Jeffery M. Dyck • Vicki Moran

Nurse Educator’s Guide to Best Teaching Practice A Case-Based Approach Keeley C. Harmon, PhD, RN Joe Ann Clark, EdD, RN (Retired) Our Lady of the Lake Regional Our Lady of the Lake College Medical Center Baton Rouge , LA , USA Baton Rouge , LA , USA Vicki Moran, PhD, RN, CNE, APHN-BC Jeffery M. Dyck, MSN Saint Louis University British Columbia Institute of Technology St Louis , MO , USA Burnaby , BC , Canada

ISBN 978-3-319-42537-5 ISBN 978-3-319-42539-9 (eBook) DOI 10.1007/978-3-319-42539-9

Library of Congress Control Number: 2016948212

© Springer International Publishing Switzerland 2016 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made.

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This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG Switzerland First, I dedicate this book to the many educators I have known over the years who have worked tirelessly to develop teaching methodologies which would more effectively meet their student’s needs. Second, I dedicate this book to my daughter Keeley Harmon who encouraged/pushed her mom to become a part of this endeavor. For this, and her constant encouragement, I thank her. —Joe Ann Clark. I dedicate this book to my understanding and loving family: To my children, Nicholas and Elise, and to my mother, Joe Ann. Nothing I do in this life could be accomplished without their love, patience, and support. This book is also dedicated in loving memory of my dearest father and late husband, Alan. I feel their guidance and support in a heavenly way. I also dedicate this book to the hardworking nurse educators who work diligently and strive to provide our future nurses with an education focused on promoting the best patient care outcomes through our constantly changing healthcare environment. —Keeley C. Harmon. Heartfelt thanks to my patient and understanding family, who so often have to report, “Dad’s at his computer again!” I am sincerely indebted to the leaders in the nursing department at the British Columbia Institute of Technology, who have shown remarkable ﬂ exibility, foresight, and empathy in allowing me to craft a unique working arrangement. Finally, I dedicate this work to the many students whom I’ve had the privilege to teach and who are so eminently worthy of not only sustaining, but growing, this fascinating profession. —Jeffery M. Dyck. I am truly inspired by many people in my life to which I dedicate this book. First and foremost to my husband, who has supported and created a culture in our family to reach for the stars and if you work hard enough, you will achieve what you deserve. Second, to my ﬁ ve children, who think I am always texting people! Finally, to the many nursing educators that I work with. The ability to transform this profession starts with how we create critical thinking, compassion, and care in the classroom and clinical setting with the students. —Vicki Moran. Pref ace

It is the belief of the authors that nurse educators are important people! This statement is not true just because the authors, who happen to be nurse educators, pro- claim it, but because it is also documented in the literature. The National League for Nursing (NLN), in its 2002 statement on the preparation of nurse educators, stated: “Nurse Educators are the key resource in preparing a nursing workforce that will provide quality care to meet the health care needs of our population” (NLN Board of Governors, 2002). Halstead (2011) writes that nurse educators “infl uence the future of the profession through the quality of the nurses they prepare to practice” (p. 357). “Key resource in preparing the nursing workforce”—“infl uence the future of the profession”! Those are strong statements that emphasize the importance of what nurse educators do. Indeed, they make the faculty role tempting to the nurse who wishes to be a part of the process. However, there is also evidence indicating that teaching is not easy. Brookfi eld (2006) describes it as “an activity full of unexpected events, unlooked-for surprises and unanticipated twists and turns that takes place in a system that assumes that teaching and learning are controllable and predictable” (p. xi). Brookfi eld’s description of teaching certainly applies in nursing, whether in a classroom, laboratory, online, or clinical environment. All are fertile ground for unexpected surprises, twists and turns. It is sometimes implied that because nurses teach patients and staff, it follows that teaching nursing students comes naturally. “All nurses are teachers” is a familiar—but dubious—adage. The role of the nurse educator is intricate. Over time, nursing education has moved from the service sector to college and university settings, and the role of nursing faculty has evolved and become increasingly complex (Finke, 2009, p. 3). It requires the knowledge and application of teaching methodologies in varied learning environments with nontraditional students. Educators work with students from diverse cultures and backgrounds with different learning styles. Educators construct and analyze tests and counsel students. They are role models in terms of demonstrating caring, not only for patients and families, but for students as well. They need to walk a fi ne line between expressing their concern for their students and not fostering dependence. Above all, they are expected to prepare

vii viii Preface graduates who can function safely and competently in an ever-changing healthcare environment. These skills are very different from the skills that one learns when becoming a nurse! The qualifi cations of nurses who decide to enter nursing education vary. Many are advanced practice nurses who have a background of rich clinical experience but scant teaching experience. Novice educators may have experience in teaching, but little clinical experience. These groups may be very different but they have one need in common—tools for becoming more skilled teachers. It is not the purpose of this book to be a compendium of all that is known about the topic of teaching in nursing. Rather, it is the premise of the authors that there is a need for a resource to assist nurse educators, the novice and the more experienced, in working through some of the issues and challenges they are likely to encounter in their day-to-day teaching experiences. This book is designed to be an easy-to-use handbook of essential teaching skills and tools for nurse educators. Preceded by a discussion of the principles of teaching and learning, it explores topics such as classroom teaching, clinical experiences, teaching in the simulation laboratory, and online learning. Each chapter begins with information about the basics of teaching and learning in that specifi c environment, followed by scenarios that focus on the issues most commonly encountered by faculty in that environment. The scenarios present a variety of actions the faculty member may take and describe rationales and/or potential problems that result from these actions. The chapters also include specifi c tools and information designed to assist the reader in preparation for the teaching role, such as examples of course syllabuses and activities in the clinical area. This information is derived from the experiences of the authors, each of whom started teaching as a novice and over the years has developed tools and techniques designed to assist both the faculty member and the learner. This book is our opportunity to share our knowledge and experience and thereby assist nurse educators who are just getting started and trying to “fi gure out” how to begin as well as other more experienced faculty who would like to try other approaches to enhance their teaching.

Baton Rouge, LA, USA Keeley C. Harmon, PhD, RN Baton Rouge, LA, USA Joe Ann Clark, EdD, RN Burnaby, BC, Canada Jeffery M. Dyck, MSN St. Louis, MO, USA Vicki Moran, PhD, RN, CNE, APHN-BC

References

Brookﬁ eld, S. (2006). The skillful teacher: On technique, trust, and responsiveness in the classroom. San Francisco, CA: Wiley. Finke, L. (2009). Teaching in nursing: The faculty role. In D. Billings, & J. Halstead (Eds.), Teaching in nursing: A guide for faculty (3rd ed.). Philadelphia, PA: Saunders. Preface ix

Halstead. (2011). The realist adjusts to sails: A commitment to transform nursing education models. Nursing Education Perspectives, 32 (6), 357. NLN Board of Governors. (2002). Position statement: The preparation of nurse educators . Retrieved May 24, 2016, from http://www.nln.org/docs/default- source/advocacy-public-policy/the-preparation-of-nurse-faculty.pdf?sfvrsn=0 .

Contents

1 Issues and Trends in Nursing Education ...... 1 An Educator’s Perspective ...... 1 Joe Ann Clark ...... 1 History of the Development of Nursing Education ...... 7 Educational Pathways to Become an RN ...... 9 Regulation of Nursing Schools ...... 9 NCLEX-RN History ...... 10 Student Population ...... 12 Faculty Role ...... 13 Conclusion ...... 14 References ...... 14 2 Principles of Teaching and Learning...... 17 An Educator’s Perspective ...... 17 Vicki Moran ...... 17 The Seven Principles of Good Practice in Undergraduate Education ...... 18 Additional Principles of Teaching Nursing ...... 20 Student Centeredness ...... 20 Scenario One: Student Engagement ...... 20 R e ﬂ ective Practice ...... 21 Scenario Two: Reﬂ ection ...... 21 Teaching Philosophy ...... 22 Team ...... 22 Vulnerability ...... 23 Learning Environment ...... 23 Scenario Three: Learning Environment ...... 24 Adult Learners ...... 24 Scenario Four: Developing Reciprocity and Cooperation in Students ...... 25 Conclusion ...... 26 References ...... 26

xi xii Contents

3 Classroom Teaching ...... 27 An Educator’s Perspective ...... 27 Keeley Harmon ...... 27 Scenario One: The Basics ...... 28 Scenario Two: Classroom Engagement ...... 33 The Flipped Classroom ...... 34 Scenario Three: Helping the Student Who Is Failing a Nursing Course ...... 36 Scenario Four: Incivility in the Classroom ...... 38 Scenario Five: Choosing Appropriate Test Items for Course Examinations ...... 40 Scenario Six: Academic Integrity: Cheating on Examinations ...... 43 Methods Used by Students to Cheat ...... 44 What About Cheating on Assignments? ...... 45 What Should You Do If You Suspect Cheating During a Classroom Exam? ...... 45 Conclusion ...... 46 References ...... 46 4 Clinical Experiences ...... 49 An Educator’s Perspective ...... 49 Keeley Harmon ...... 49 Scenario One: Being a Clinical Instructor for the First Time —What Do I Do? ...... 50 Scenario Two: Supporting a Student Who Is Performing a Skill for the First Time in Clinical ...... 54 Scenario Three: Unprepared Student ...... 56 Managing Clinical Unpreparedness When It Occurs ...... 58 Scenario Four: Not Enough Time—Spending Appropriate Time with Each Student ...... 59 Scenario Five: Today’s Student ...... 60 Scenario Six: Proper Feedback on Summative Clinical Evaluative Tools ...... 63 Scenario Seven: The Great Intimidator ...... 64 Faculty and Student Behavior Considered to Be Uncivil ...... 65 What About Faculty That Tip the Scale and Want to Be Everyone’s Best Friend? ...... 65 Scenario Eight: Promoting Professionalism in Our Students ...... 66 Conclusion ...... 66 References ...... 66 Contents xiii

5 Simulation ...... 69 An Educator’s Perspective ...... 69 Vicki Moran ...... 69 Scenario One: Basics of Simulation Preparation ...... 74 Scenario Two: Students that are Unprepared ...... 76 Scenario Three: Letting a Student Fail ...... 76 Scenario Four: Reducing the Anxiety of Simulation ...... 77 Conclusion ...... 78 References ...... 79 6 Online Learning ...... 81 An Educator’s Perspective ...... 81 Jeffery M. Dyck ...... 81 Scenario One: How Can I Best Get Up to Speed on My School’s LMS? ...... 83 Prevalence and Growth of Online Courses in Nursing ...... 85 Instructors’ Perceptions of Feeling Unprepared...... 86 Scenario Two: Preventing a Lack of Engagement ...... 92 Scenario Three: Promoting Community ...... 96 Scenario Four: How Can I Prevent Academic Dishonesty ? ...... 101 Scenario Five: How Can I Stay Connected with My Department and My Colleagues When Teaching from a Distance? ...... 105 Conclusion ...... 108 References ...... 109

Appendix A: Example Course Syllabus ...... 111

Appendix B: Program Outcomes ...... 113

Appendix C: Exam Blueprint ...... 115

Appendix D: Example Case Study ...... 117

Appendix E: Example Welcome Letter ...... 119

Appendix F: Key Discussion Points During Advising ...... 121

Appendix G: Clinical Organization Tool ...... 123

Appendix H: Example of Clinical Syllabus ...... 125

Appendix I: Abbreviated Second Patient Form ...... 129 xiv Contents

Appendix J: Example of a Clinical Contract...... 131

Appendix K: Sample Action Plan ...... 133

Appendix L: Sample of Debriefing Questions for Simulation ...... 135

Index ...... 137 Chapter 1 Issues and Trends in Nursing Education

An Educator’s Perspective

Joe Ann Clark

In the early stages of preparation for this book, the authors (who collectively have about 80 years experience in nursing education) spent much time discussing their experiences as nurse educators. Their discussions focused on many of the issues in nursing education, changes they had witnessed over the years, and challenges which impacted them as nurse educators. We noted that as nurse educators we felt concern, especially when we were ﬁ rst starting out, as we were ill-prepared for the role and had often taught ourselves the skills we needed to get through the day. We questioned if we had been as effective as we could in helping our students achieve their educational goals . I started my nursing education in 1951 in a diploma program which was in the earliest stages of transitioning into a baccalaureate program. When I entered the program as a student, the requirements for admission were that you have “good” grades in high school, pass the entrance examination, be at least 5 feet tall, and weigh within “normal” range for your height. Tuition at that time was $125.00 for the ﬁ rst year—that included room and board, textbooks, uniforms, and laundry of uniforms. The second year, tuition was $50.00 and the third year, $25.00. That was because during the second and third year students were, in varying degrees, utilized as staff in the hospital. Almost all of the students were young (a few of us had a couple of semesters of college), all were female, and most just out of high school. No one was permitted to be married, and you could not marry while in school. We were all required to live in the dormitory and obey all of its rules. The hospital of those days was very different from the clinical environment in which student learning takes place today. First of all, the patient units were com- posed of large rooms in which 20 or more patients were placed. There were typically two such large rooms per unit. The beds were the old “crank” type which would elevate and lower the head and feet. That was all they were capable of doing!

Each patient had a bell to ring if they needed something—or they just yelled! There were no “contour” sheets, so students were taught to tuck in the sheets, military style, in such a manner that they would not move. The beds were placed along the walls, with pull curtains which could be drawn to provide privacy. However, there was no air conditioning, so it was very hot and when the curtains around the beds were drawn, it was even hotter. One good thing about this arrangement (when the curtains were open) was that you could take one look around the room and see what was happening with every patient. Each of these nursing units also had one or two private room for the very sick and/or new postoperative patients. There were no recovery rooms or intensive care units. There were a few isolation rooms, but not on every unit. The confi guration of those rooms included an elaborate entrance/exit area which contained all the supplies that a nurse would need to enter and exit the room. Isolation was fastidiously maintained, a practice that predated the discovery of antibiotics. There was rampant, active tuberculosis, all sorts of wound infections, and hepatitis. Tuberculosis was so prevalent that I became positive for TB during my fi rst semester in school. There was a very small nurse station which included space to pour medications and equipment for treatments. Medications were kept in large bottles—no prepack- aged medications. Nurses had to calculate how many pills to give or how to break up the pills in order to provide the proper dose for their patients. The proper dosage was put into a medicine cup, which was glass. After medications had been given the cups had to be washed and sterilized. Injections were a big part of nursing care. Almost everyone on medical–surgical units was given penicillin three to four times a day. Syringes were glass and they had to be washed and sterilized on the unit after each use. Needles were metal and nurses had to check them before use and sharpen them when they were dull. The needles also had to be cleaned after each use and sterilized in the small sterilizers on each unit. IV bottles were glass; most tubing was rubber, although plastic was beginning to be used. All rubber tubes on the unit (urinary catheters, gastric tubes, etc.) had to be cleaned and returned to central supply to be autoclaved. Enema tubes were washed after use and placed in a container to soak in a soap solution. Bed pans were washed and after a patient was discharged, they were boiled. The fact at that time was nothing was disposable ! Nurses had to prepare sterile normal saline, enema solutions, dermatology soaks, and other solutions on the unit in the treatment room. They had to add medications to IV bottles in this same room which was the setting for all sorts of tasks. For every kit that was used, for example, a catheterization kit , the nurse or student had to clean the equipment and then return it to central supply to be autoclaved. Rubber gloves were kept on the units, to be used for “special things” such as dressings and cathe- terizations, but after each use, the nurse had to wash the gloves, put them on a rack to dry, powder them when they were dry, and fi nally wrap them in linen to be returned to central supply for autoclaving. For patients with diabetes, urine had to be checked every 4 h for glucose levels. The nurse had to collect the urine and take it to the treatment room where there was a metal tent to prevent the urine from splat- tering all over the room. The urine was placed in a test tube with Benedict’s solution and boiled, which would turn the urine a different color depending on the amount of An Educator’s Perspective 3 sugar present. The appropriate dose of insulin would then be calculated and given. I will never forget the smell of cooked urine! Nursing faculty taught in the classroom, clinical setting, and laboratory. In the Nursing Fundamentals course, the faculty not only had to teach the procedure but also the care of the equipment, calculation of medication dosage, etc. However, in the following courses, faculty assigned students to clinical units to provide learning experiences for the specifi c courses they were taking. Assignments on the units and work schedules were made by the head nurse, who also evaluated the student’s clinical performance. Each course was heavy with clinical hours, and after the fi rst semester, students’ clinical learning experiences were in reality “service hours.” Upon completion of the fi rst semester students were assigned not only to the day shift but also to the 3:00 p.m. to 11:00 p.m. and 11:00 p.m. to 7:00 a.m. shifts including weekends. The total number of hours students were assigned each week varied, but the rule seemed to be that the combined classroom and clinical hours could not exceed 40 h. Assignments were task oriented; students might be assigned direct patient care on an acutely ill patient, or group of patients, or as “medicine” or “treatment” nurses. On the evening shifts, night shifts, and weekends, there were no nursing faculty in the hospital and students worked closely with the nursing staff. During their senior year, especially on evenings, nights, and weekends, students often served as charge nurse. Classroom teaching was scheduled during the day. Students could not be scheduled to work during classroom hours but those who did work evening or night shifts were expected to be in class during the day. It was common, on the weekends when students had no classes, to assign students “split shifts.” For example, on Saturday and Sunday, the hours assigned often were 7:00 a.m. to 12:00 p.m. and 4:30 p.m. to 7:00 p.m. This assured that students were there to “pass” medicines, provide baths, and give evening care (evening care at that time consisted of a back rub; brushing of teeth and a face wash; smoothing or change of linens; and a little conversation). After I completed the diploma program, and because I had previously completed the basic education courses required for the degree, I was able to take an additional course, a newly developed public health/community course required for the Bachelor of Science in Nursing (BSN) . I was one of the fi rst of three graduates in the newly developed BSN program. In 1955, after graduating and passing the national licensure examination, I was immediately recruited to become a faculty member at the school. The reason for the program’s interest in me as a potential faculty member was simple: the program was transitioning into a baccalaureate program, and it was evident that the academic requirements for faculty would soon be the BSN. The fact that I had absolutely no teaching or clinical experience was not a deterrent. I had the required degree (not many nurses at that time did), so I was hired. Thinking back, I don’t know what in the world made me feel I was prepared for this challenge! For the fi rst two semesters, I was assigned to work with a more experienced faculty member and felt I was beginning to learn a little something about teaching. I was assigned to teach very few of the classes and received little guidance about how the class I was to teach fi t in with the rest of the course. Also, the tests I was provided had been written in previous years. I did not know this at fi rst, so I had no idea if the content I taught was appropriate to prepare the students for the test. There was no real orientation to the practice of teaching in the classroom. My preparation 4 1 Issues and Trends in Nursing Education for clinical teaching was a directive to get the students as many procedures as possible and to be sure and check their charting. When my more experienced faculty member resigned to pursue her master’s degree in Texas, I became the senior faculty member for the fundamental nursing course. I was responsible for all the classroom teaching, testing, teaching in the laboratory, and for coordinating clinical supervision of students in the hospital. I had someone to assist in all of this, but she had even less knowledge and experience than I did. There was no faculty orientation or assistance, so I just taught as I had been taught and as the faculty member before me had taught. In the classroom, I lectured and attempted to encourage discussion among the students. It was diffi cult to think about teaching strategies as I was preparing for lectures every night and just barely staying ahead of the students. The nursing laboratory experience was, to say the least, very interesting. The teaching methods used were, I am sure, as old as nursing itself. Looking back on it, I don’t know how in the world we got away with it. Today, the students would probably bring suit against us for doing invasive procedures on them! Demonstrations of procedures were done fi rst by the instructor. That wasn’t hard for me because I had just been a student myself and did it in the same manner I had been taught. Following the demonstrations, students were then expected to practice by doing a return demonstration of the procedure with one of their classmates acting as the patient. They gave each other baths, provided evening care, took vital signs, drew blood, inserted nasogastric tubes, and gave injections (sterile saline, of course). The rationale for this teaching approach was twofold: (1) the student needed to have experience in the laboratory before doing procedures on patients in the hospital and (2) students needed to empathize with how the patient felt when receiving care. All of those return demonstrations were very time consuming for both the student and faculty member, but it certainly motivated students to practice! In my teaching experience during that time, my biggest challenge was creating tests. The tests had to be created a few days before the scheduled test date so that the secretary could type and duplicate them. As a result, the test writing process was done in a hurried manner with no time to really look at the test as a whole or to ask another faculty member to review it. Altogether, writing lectures and tests, doing the nursing laboratory demonstrations and clinical assignments, supervision, and evaluations were overwhelming. Many of those early teaching experiences were diffi cult, frustrating, and scary. I continued in my position as a nursing instructor for the next few years, at times feeling more competent as a teacher in some areas but in other areas feeling inadequate and frustrated. After the birth of my second child in 1958, I took time away from nursing education. During the 1970s, after our youngest child was almost ready to start school, I decided it was time to return to nursing and, frankly, as a fairly young couple, my husband and I needed the extra income. I recognized that I needed to update my clinical skills and went to work in a hospital which had an orientation program for nurses who had been out of nursing for an extended period of time. There was a nursing shortage at the time and hospitals were doing all they could to assist nurses in making that adjustment. The hospital also had a diploma in nursing education program and after I had worked as a staff nurse for a short time, they recruited me to return to nursing education. I was hesitant because I felt I needed more time to An Educator’s Perspective 5 regain my skills, but was assured that I would be given all the support I needed. Again, at this time, there was a real shortage of academically prepared nurses to teach and even though I had been out of nursing for several years, I was hired. After a short time, I again asked myself, “What in the world made you think you were really prepared to teach?” It did not take long before I began to experience the same feelings of frustration and inadequacy that I had in my previous teaching experience. Despite the passing of nearly two decades, teaching at this school was not all that different from my previous teaching experience in the 1950s. In the early 1970s, students were still very young and female, could not be married without permission, and were required to live in the dormitory. Requirements for entrance into the program were about the same as they had been in my previous school. The applicant had to have good grades, pass an entrance examination, and submit reference letters. Some years there were not enough qualifi ed applicants to fi ll a class and other years there were more than enough. However, after the nursing shortage became more severe in the 1970s, the number of applicants grew every year; the entrance requirements became more and more stringent and we began to have a lot more applicants than we had space for students. The school had a very good reputation throughout the state and its pass rate on the licensing examination was extremely high. The hospital at that time had advanced—somewhat. There were recovery rooms and acute care units, and the rooms were air-conditioned. Needles and syringes came in various sizes and were disposable. Gloves were disposable as well, but used only for special procedures. Plastic IV tubing was available but solutions still came in bottles, with medications being added by the nurse, on the unit. Kits for purposes such as catheterization and dressing changes came from central supply and had to be cleaned and returned for autoclaving. Most of the rooms housed two patients, though the beds, for the most part, were still the old crank-type. Overall, however, technology and equipment were changing and advancing every year. The minimum academic requirement for faculty was the Bachelor of Science Degree in Nursing but the State Boards of Nursing was beginning to emphasize the need to increase the minimum requirement. In the 1980s, due to pressure on the national and state level, the Master of Science in Nursing degree was required for nursing faculty. Teaching at this school in the 1980s was not all that different from my previous teaching experience in the 1950s. Following a brief orientation to the curriculum and school rules , I was assigned to teach with a more experienced faculty member who, again, taught as she was taught: lecture in the classroom, laboratory demonstrations, and heavy clinical assignments. I was assigned certain lectures to present and again did not know that test questions were already written. My major responsibilities were to assist in the lab. Because the lab was small we had to repeat sessions in order to accommodate all the students. I also had a group of students in the clinical environment for 4 days a week. The major difference in the clinical area was that students were no longer utilized as staff and the faculty member was always present on the unit to supervise students. One asset of the diploma programs of the day was the quantity of clinical experience. Students had clinical for 4 days or evenings a week in every course. In the fundamentals course, students were assigned clinical for 4 h a day, 4 days a week. 6 1 Issues and Trends in Nursing Education

The change in the student over the 4-day period was remarkable. The fi rst day or two, students were nervous and anxious but by the fourth day, for the most part, they were confi dent and self-assured. They were expected to be well prepared—getting their assignments the day before, visiting their patients, reviewing the chart, and preparing a plan of care. As the courses progressed, the hours were longer and patient assignments became more complex. Four day clinical assignments gave them added confi dence and expertise as they progressed through the program. The curriculum was focused around the medical model and students were now required to complete a course in anatomy and physiology that was taught by a professor from a nearby university. The content was the same as what he taught at the university to the medical students. Then, in 1978, everything began to change. The hospital moved into a new “state- of-the-art” facility. The school of nursing moved with the hospital—with classrooms and a laboratory in the hospital but no dormitory—and we quickly became a com- muter school. The student body began to change and became more diverse with a higher number of nontraditional students (25 years and older). Some of these nontraditional students were married with children, some were single parents, some were individuals seeking second careers, and, lastly, some were attracted to the profession not because of their desire to serve, but solely because of the availability of jobs after graduation. Most of the students held jobs outside the program and had little time for anything they considered “busy work.” The State Boards of Nursing made it clear that, within a designated period of time, the Master’s of Nursing Degree would be required for nursing faculty. Therefore, most of the faculty, including myself, were going back to school; I received my master’s degree in 1980. In the early 1980s, as a result of the nationwide trend of moving diploma nursing education programs from the hospital setting into institutions of higher learning, the decision was made to establish a free standing college to offer an associate degree (A.D.) in nursing and other allied health fi elds. This began a long process involving visits to institutions offering the associate degree and accrediting agencies, choosing a curriculum model, and designing nursing courses. Consultants were brought in to critique and assist the faculty’s efforts and to ensure that everything met the requirements of the State Boards of Nursing and accrediting agencies. Faculty were excited about the proposed changes and the fact that they were supported and included throughout the process. Even though faculty were stretched very thin during this transition, developing the new A.D. program while still teaching in the diploma program as it was being phased out, they went to great lengths to minimize any negative impact on students. During this period, I enrolled in a program to complete a doctorate in higher education and graduated in 1990. When the transition was completed, the new A.D. Program received full approval from the State Boards of Nursing and full accreditation from the regional accreditation agency on the fi rst try! Upon graduation, students in both the diploma and A.D. programs scored high on the NCLEX-RN and student exit evaluations of the programs were very positive. We saw this as a tremendous achievement, made possible because faculty felt a part of the process and were given the support and preparation they needed. History of the Development of Nursing Education 7

In summary, as I look back, I have seen many changes in nursing education . To name a few: • The movement of nursing programs into institutions of higher education • Changes in healthcare delivery • Changes in curriculum design to more effectively prepare students to function in the health care environment • An increasingly diverse and nontraditional student population • Changes in technology, both in education and health care • Increased requirements for approval by the State Boards of Nursing and for accreditation by national accrediting agencies • Changes in academic requirements for nursing faculty However, an unfortunate constant in my observations is the lack of preparation for nursing faculty in the basic skills of teaching. This book is designed to provide practical, simple, and effective guidelines for the beginning nurse educator. The book begins with a history of nursing education, information about the regulation of nursing schools, the ever-changing student population, and the faculty role. Further chapters contain content relating to principles of teaching and learning, classroom teaching, teaching in the clinical environment, simulation, and online teaching. Each chapter contains basic information related to the chapter content, followed by scenarios which illustrate a variety of teaching situations which includes potential actions and rationale for each action.

History of the Development of Nursing Education

The ﬁ rst nurse training programs in the USA were established in 1872. Women’s Hospital in Philadelphia and New England Hospital for Women and Children were nurse training programs staffed with women physicians who sought quality nursing care (Kalisch & Kalisch, 2004). Three more nurse training programs supported by hospitals opened in 1873. Bellevue Hospital Training School in New York, Connecticut Training School in New Haven Hospital, and Boston Training School in Massachusetts General Hospital opened with the support of laywomen. The majority of schools established before the 1900s were on either the east or west coast, with just a few training schools elsewhere in the country (Kalisch & Kalisch, 2004 ). By 1900, 490 nurse training schools had been established in the USA. Many of these schools were speciﬁ cally created to care for patients with the prevalent ill- nesses of the time, such as mental illness and tuberculosis (Kalisch & Kalisch, 2004 ). Hospital administrators found that it was more economical to have an internal nurse training program than hiring nurses from outside the institution. In general, students worked 12-h days and many of their classes were canceled when their services were needed within the hospital. Nursing leaders soon recognized the need to establish standards for college and university nursing faculty programs. In 1919, the Rockefeller Foundation funded 8 1 Issues and Trends in Nursing Education

The Committee for the Study of Nursing Education to study nursing education in the USA. The committee charged Josephine Goldmark, a social worker, to lead the investigation and it resulted in the publication of Goldmark Report in 1923. The committee’s original mandate was to “examine the proper training of public health nurses” (Committee for the Study of Nursing Education, 1923, p. 7). However, the focus broadened to research “the entire problem of nursing and of nursing education” (Committee for the Study of Nursing Education, 1923 , p. 7). The report highlighted the fact that other professions, like medicine and law, had moved away from an apprenticeship model. In contrast, nursing had been directed by “organizations created and maintained for the care of disease, rather than for professional education” (Committee for the Study of Nursing Education, 1923 , p. 17). The report’s recommendations included the establishment of a university-based school of nursing with a separate governing board and fi nancing separate from hospitals. University education also was recommended for future nursing educators. The report called for the standardization of nursing education and the extrication of nursing education from American hospitals (Ruby, 1999 ). The Society of Superintendents of Training Schools, which later became the National League of Nurse Education (NLNE) , attempted to establish a standard curriculum for nursing programs. The league believed the standardization of curriculum would ensure that nurses were taught similarly and to a high standard in all schools of nursing (Committee on Curriculum of the National League of Nursing Education, 1937 , p. 4). The Standard Curriculum for Nursing Schools was published in 1917 by the Education Committee of the NLNE under the leadership of Adelaide Nutting. The curriculum was divided into two major sections. The fi rst section outlined the physical facilities, fi nancial resources, and administrative control of the schools. This section also addressed the qualifi cations of the students and faculty, guidelines for student life, and recommended methods of teaching. The second section was a detailed curriculum plan with objectives, content, methods, resources, and operational schedules (Education Committee of the National League for Nursing Education, 1917 ). However, the standard curriculum was merely a guideline and not adopted in its entirety by all nursing schools. After the Goldmark Report of 1923, two revisions were made to the original curriculum publication and it was retitled A Curriculum Guide for Schools of Nursing . The fi nal revision in 1937 identifi ed “well-supported suggestions and recommendations in relations to desirable objectives, sources, content, methods, and organizations” (Committee on Curriculum of the National League of Nursing Education, 1937 , p. 10). The authors sought to provide a framework for schools of nursing, and A Curriculum Guide for Schools of Nursing was intended as a handbook to be used by an individual school in building its own curriculum. The authors believed nursing education should be in harmony with the principles and methods of modern science (Committee on Curriculum of the National League of Nursing Education, 1937). This was a chalenging necessity due to the rapid changes in the health care, science, and social arenas. Another famous report on nursing education was published in 1948. Ester Lucille Brown’s report entitled Nursing for the Future recommended that schools of nurs- Regulation of Nursing Schools 9 ing be placed in colleges and universities, similar to the Goldmark Report (Brown, 1948). The Brown Report also supported the release of nursing education from hospitals and a standard curriculum (Ruby, 1999 ).

Educational Pathways to Become an RN

Today, there are three educational pathways to become a registered nurse in the USA: the Associate Degree in Nursing (ADN), Associate of Science in Nursing (ASN), and Bachelor of Science in Nursing (BSN). Graduates of all the pathways are eligible to take the NCLEX-RN. Typically, ADN or diploma programs are approximately 3 years in length and mimic the original hospital-based training programs (AARP, 2010 ; Institute of Medicine, 2011 ). The Associate of Science in Nursing [ASN] program originated following the end of World War II in 1945. Advances in health care and dramatic increases in the number of new hospitals from the Hill-Burton Act of 1946 increased the demand for nurses and a shortage of hospital nurses ensured (Orsolini-Hain & Waters, 2009 ). In response, a 2-year nursing program was created and was offered at junior and community colleges. Graduating students received an ASN and qualiﬁ ed to test for licensure as a registered nurse (RN) (Matthias, 2010 ). Currently, ASN programs require 2 years of nursing instruction and are typically offered by community colleges (AARP, 2010; Institute of Medicine, 2011 ). The Goldmark Report of 1923 and the Brown Report of 1948 encouraged colleges and universities to cultivate baccalaureate nursing programs in institutions of higher education. The number of such programs has grown steadily since that time (Orsolini-Hain & Waters, 2009 ). Currently, about 55 % of the American RN workforce holds a bachelor’s or higher degree (Health Resources and Services Administration [HRSA], 2013). Differentiation of graduate competencies among the entry-level education programs— ADN , ASN , and BSN —may exist, but differentiation of nursing practice among entry-level prepared RNs do not (Matthias, 2010 ).

Regulation of Nursing Schools

The regulatory body mandated to oversee and approve education in each state and territory in the USA is the State Boards of Nursing (SBON) (NCSBN, 2004 ). Each SBON either approves or accredits nurse education program in schools and universities (NCSBN) . SBON program approval/accreditation is for the purpose of protecting the health, safety, and welfare of the public (NCSBN). Each state or territory has a Nurse Practice Act (NPA) enacted by the state legislature. The Boards develop rules and regulations to clarify aspects of the NPA, including the establishment of standards for pre-licensure education. These standards vary from state to state on 10 1 Issues and Trends in Nursing Education issues such as required curricular content, types and number of clinical experiences, faculty qualifi cations, and ratios of students to faculty members (Glasgow, Niederhauser, Dunphy, & Mainous, 2010 ). The SBNs evaluate nursing schools by comparing the NCLEX-RN pass rate of the school to the national average. National nursing accreditation is a voluntary, nongovernmental peer-review process to assure that schools of nursing are meeting standards (NCSBN, 2004 ). There are two major nationally recognized accreditation agencies for nursing programs. The AACN developed the Commission on Collegiate Nursing Education [CCNE] in 1998 and accredits baccalaureate and graduate degree including doctorate of nursing practice programs (AACN, 2014 ). The National League of Nursing Accreditation Committee [NLNAC], formed in 1996, accredits diploma, associate, and baccalaureate programs. As a result of the continued demand for accreditation services, the NLNAC changed its name to the Accreditation Commission for Education in Nursing or ACEN in April 2013 (ACEN, 2013 ). “The purpose of the ACEN is to provide specialized accreditation for programs of nursing education, both postsec- ondary and higher degree, which offer either a certifi cate, a diploma, or a recognized professional degree (clinical doctorate, master’s, baccalaureate, associate, diploma, and practical)” (ACEN, 2013 , p. 1). Both agencies require a self-study for accreditation, focusing on identifi ed standards set by each accrediting agency. Both agencies use NCLEX-RN pass rates as one measure for approval in the accreditation process. In most cases, schools follow the accreditation process every 10 years.

NCLEX-RN History

Nursing has the potential to cause harm to the public if practiced by unprepared or incompetent practitioners. Licensure is a method put into place to assure the public that a nurse has obtained the necessary skills to practice in each state or territory in the USA An individual qualifi es for licensure by completing a nursing program and by passing the NCLEX-RN examination (NCSBN, 2016 ). The test plan of the NCLEX-RN is a set of content categories that defi ne nursing actions and competencies across all settings for all clients (NCSBN, 2016 ). The NCLEX-RN is developed and revised by NCSBN based on extensive analysis of the practice requirements of an RN (NCSBN, 2013). The NCLEX-RN test plan is categorized by the client needs presented in Table 1.1 . This table also identifi es the percentage of items on the examination from each of the categories and subcatego- ries for the 2016 NCLEX-RN test plan. The NCLEX-RN examination uses a variety of types of questions, including multiple response, multiple choice, fi ll in the blank items, hot spot items (where the candidate needs to locate an anatomical point on a diagram or body), ordered response items, chart and graph items, and items that use computer technology (Lavin & Rosario-Sim, 2013 ). NCLEX-RN test items are written at a higher level of thinking in order to test the applicant’s ability to process complex patient care issues. Bloom’s taxonomy is a way to categorize the hierarchy of cognitive processes using NCLEX-RN History 11

Table 1.1 2016 NCLEX-RN examination test plan areas and percentage of items Percentage of items from each category/ Client needs subcategory Safe and effective care environment Management of care 17–23 % Safety and infection control 9–15 % Health promotion and maintenance 6–12 % Psychosocial integrity 6–12 % Physiological integrity Basic care and comfort 6–12 % Pharmacological and parenteral therapies 12–18 % Reduction of risk potential 9–15 % Physiological adaptation 11–17 % Source: NCSBN, 2016 . NCLEX-RN test plan. Retrieved from https://www.ncsbn.org/RN_Test_ Plan_2016_Final.pdf Reprinted with permission from National Council of State Boards of Nursing a leveled approach. The use of Bloom’s taxonomy is considered the “gold standard and hallmark of behavioral objectives and is divided into six levels of learning: recall, grasp, apply, analyze, synthesize, and judge” (Cannon & Boswell, 2012 , p. 140). Diagram 1.1 identiﬁ es the levels included in Bloom’s Taxonomy. The lowest level identiﬁ es where basic knowledge/recall is assessed. The NCLEX-RN uses questions developed at the application and analysis levels which require more complex thought processing than simply knowledge or comprehension (NCSBN, 2013). Prior to 1986, each SBON administered their own nursing examination. Often referred to as the Board exam, the number of questions a student completed ranged from 350 questions to 1200 depending on the SBON. The NCSBN began to administer the exams for all SBON in the 1970s, streamlining the exam to a few hundred questions. In 1986, the NCSBN Board of Directors investigated the use of new technology to administer the NCLEX-RN exam. Computer Adaptive Testing , or CAT NCLEX-RN, allowed the examination to be given at any time, shortened the examination length, and provided greater security of test items (NCSBN, 2016 ). During the CAT NCLEX-RN examination, the computer constantly calculates an ability estimate of each question, matching the question to the test plan requirements. The candidate receives questions until the computer determines that the minimum amount of items has been achieved and the computer determines with 95 % certainty that the candidate represents safe entry-level competence (NCSBN, 2013). To identify whether a candidate is above or below the passing standard, the computer needs the current ability estimate of the candidate, the precision of the estimate, and the passing standard. Today, each candidate answers a minimum of 75 and a maximum of 265 questions using the CAT NCLEX-RN. Every 3 years the NCSBN administers a practice analysis survey. The survey is sent to recent nursing graduates, schools of nursing, and hospitals and asks participants to identify current trends in nursing practice. The results of this practice analy- 12 1 Issues and Trends in Nursing Education sis inform the content tested on the NCLEX-RN. Also included in the survey are demographics about candidates who successfully passed the NCLEX-RN. Candidates who successfully passed the NCLEX-RN examination from October 1, 2013 through March 31, 2014 were included in the last practice analysis study reported in 2015. Of the respondents who completed the study, the majority (87.6 %) reported were female. The age of respondent nurses averaged 31.6 years (SD 8.8 years) (NCSBN, 2015 ). The respondents were 74.2 % White, 10.5 % African American, 6.1 % Hispanic, 4.1 % Asian, and 1.0 % Asian Indian (NCSBN, 2015 ). An associate degree (54.7 %) was the most common educational preparation for initial RN licensure. The second most frequent response was the baccalaureate degree (40.4 %) (NCSBN, 2015). The majority (72.0 %) of newly licensed RNs in this study reported working in hospitals . The next largest group, of around 15 %, reported working in long-term care while just fewer than 10 % reported working in community-based settings (NCSBN, 2015 ).

Student Population

The goal of nursing education is to prepare nurses to deliver safe, quality patient care to meet diverse patient needs, to function as leaders, and to advance science that benefi ts patients (IOM, 2011 ). The U.S. healthcare system and practice environment are constantly changing. These changes refl ect not only the diversity of the patient population but also the acuity of patients. Newer technologies such as electronic health records present both challenges and opportunities to nursing students, requiring skills in quickly adapting to changing environments. Similarly, nursing education must change and adapt by adjusting the learning environment. Nursing education has to change to keep up with the diversity of the patient care needs and the healthcare environment. As identifi ed from the practice analysis study, the nursing student population is changing. There are more males entering the profession. The average age of the nursing student is 31.6 years which suggests that nursing may be considered a career later in life (NCSBN, 2015 ). The change from a young female student to an older male student may present unique challenges to newer nursing faculty, challenges for which they lack suffi cient knowledge and experience. Besides age and gender, other student characteristics may affect students in the nursing program and faculty should be prepared to handle the challenges. Ethnicity and race, language, prior educational experience, family education experience, and prior work experience can all affect the nursing student experience (Jeffreys, 2012 ). Admission and retention is yet another area that impacts nursing education. Many scholarly articles identify admission requirements necessary for higher education institutions and because nursing schools are housed in these institutions, they are impacted. Some requirements for admission to nursing schools include American College Test (ACT), Scholastic Assessment Test (SAT), and high school grade point average (GPA). Other admission considerations may include an exam for English as Faculty Role 13 a second language, prerequisites in science or other courses, and nationally standardized admission assessment examinations. After admission to a nursing school, retaining students and graduating them are important. There are a variety of reasons, identifi ed from the nursing literature, that a student may withdraw or leave a nursing program. Student success such as passing a course or clinical is just one factor. Other factors identify cultural values and beliefs, self-effi cacy, and motivation as challenges that impact a student to complete a nursing program (Jeffreys, 2012 ). The ability to study, the class hours and schedule, fi nancial issues, and other academic services available can also impact retention (Jeffreys, 2012 ). Nursing programs should have a committee to review why students leave and have a process in place to keep retention high. Some strategies to keep retention high include early identifi cation of high-risk students, development of strategies to facilitate success, and evaluation of the developed program (Jeffreys, 2012 ). High stakes testing has been used in nursing education for several years. A high stakes test is any test that makes an important decision about a student’s achievement. Two major providers of high stakes testing in nursing are Assessment Technologies Institute (ATI) and Higher Education Systems Incorporated (HESI). These standardized, nationally normalized examinations assess readiness of students and have been cited in the literature as a strategy and predictor of outcomes on NCLEX-RN (Reinhardt, Keller, Summers, & Schultz, 2012 ). Both companies have linked NCLEX-RN success with either nursing content specifi c standardized exams and/or the comprehensive examination and have published research. Some schools of nursing have progression policies in place to dismiss a student for failure on one of these standardized examinations. It is imperative for any nurse educator to review the admission and progression policies regarding the use of high stakes testing in his or her nursing program and curriculum.

Faculty Role

The role of faculty members in nursing education has changed. Since the 1950s, SBN have encouraged advanced degrees for faculty teaching in schools of nursing. According to a Special Survey on Vacant Faculty Positions released by AACN in 2015, there was a national nurse faculty vacancy rate of 7.1 %. Most of the vacancies (90.7 %) were faculty positions requiring or preferring a doctoral degree. The top reasons cited by schools having diffi culty fi nding faculty were insuffi cient funds to hire new faculty (65.4 %) and unwillingness of administration to commit to full time additional full time positions (56.5 %). AACN (2015a , 2015b ) reported that faculty shortages at nursing schools across the country are limiting student capacity. Other current challenges for faculty involve the development of the knowledge and skills necessary to teach nursing students. The National League of Nursing (NLN) has developed nurse educator competencies for those faculty teaching in nurse educator tracks. The nurse educator master programs have been replaced by the newer role of the master prepared nurse practitioner programs. The NLN has a 14 1 Issues and Trends in Nursing Education certifi cation for nurse faculty who aspire to promote excellence in the advanced speciality role of the academic nurse educator. The Certifi ed Nurse Educator (CNE) is a mark of professionalism in nursing education . More information regarding this certifi cation can be obtained from http://www.nln.org/professional-development- programs/Certifi cation-for-Nurse-Educators .

Conclusion

Nursing education has many factors impacting its sustainability in higher education. Nursing curricula are inﬂ uenced by higher education standards as well as the dynamic and changing healthcare environment. Student characteristics also challenge educators to reevaluate educational practices to ensure that schools are graduating students that are prepared to practice in a complex healthcare environment. Faculty are also challenged to meet state and national standards and to educate in a manner that will facilitate learning of a diverse student population. The challenges are great. However, with knowledge and practice, a new educator can become pro- ﬁ cient in meeting the demands of this nursing role.

References

AARP. (2010). Providers of nursing care: Numbers, preparation/training and roles: A fact sheet. Retrieved March 7, 2016, from http://campaignforaction.org/sites/default/ﬁ les/Fact_Sheet_ Providers_NursingCare_0.pdf. Accreditation Commission for Education in Nursing. (2013). Accreditation manual. Retrieved March 7, 2016, from http://www.acenursing.org/accreditation-manual/ . American Association of Colleges of Nursing. (2008). Essentials of baccalaureate education for professional nursing practice. Retrieved March 7, 2016, from https://www.aacn.nche.edu/ education-resources/baccessentials08.pdf . American Association of Colleges of Nursing. (2014). CCNE accreditation. Retrieved March 7, 2016, from http://www.aacn.nche.edu/ccne-accreditation . American Association of Colleges of Nursing. (2015a). Nursing shortage faculty fact sheet. Retrieved March 7, 2016, from http://www.aacn.nche.edu/media-relations/FacultyShortageFS.pdf . American Association of Colleges of Nursing. (2015b). Special survey on vacant faculty positions for Academic year 2015–2016. Retrieved March 7, 2016, from http://www.aacn.nche.edu/ leading-initiatives/research-data/vacancy15.pdf . Brown, E. L. (1948). Nursing for the future . New York: Russell Sage. Cannon, S., & Boswell, C. (2012). Evidenced-based teaching in nursing: A foundation for educators . Ontario, Canada: Jones and Bartlett Learning. Committee for the Study of Nursing Education. (1923). Nursing and nursing education in the United States . New York: The MacMillan Company. Committee on Curriculum of the National League of Nursing Education. (1937). A curriculum guide for schools of nursing . New York: National League of Nursing Education. Education Committee of the National League for Nursing Education. (1917). Standard curriculum for nursing schools . New York: National League of Nursing Education. References 15

Glasgow, M. E. S., Niederhauser, V. P., Dunphy, L. M., & Mainous, R. O. (2010). Supporting inno- vation in nursing education. Journal of Nursing Regulation, 1 (3), 23–27. HRSA. (2013). The U.S. nursing workforce: Trends in supply and education. Retrieved from http:// bhpr.hrsa.gov/healthworkforce/reports/nursingworkforce/nursingworkforcefullreport.pdf . Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Jeffreys, M. (2012). Nursing student retention (2nd ed.). New York: Springer. Kalisch, P. A., & Kalisch, B. J. (2004). American nursing: A history (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Lavin, J., & Rosario-Sim, M. (2013). Understanding the NCLEX: How to increase success on the revised 2013 examination. Nursing Education Perspectives, 34 (3), 196–198. Matthias, A. (2010). The intersection of the history of associate degree nursing and “BSN in 10”: Three visible paths. Teaching and Learning in Nursing, 5 , 39–43. National Council State Boards of Nursing (NCSBN). (2013). NCLEX-RN Examination: Detailed test plan for the National Council Licensure Examination for Registered Nurses. Item writer/ Item reviewer/Nurse educator version. Retrieved from https://www.ncsbn.org/RN_Test_ Plan_2013_Educator_v2.pdf . National Council of State Boards of Nursing. (2004). White Paper on the state of the art of approval/accreditation processes in boards of nursing . Retrieved March 7, 2016, from https:// www.ncsbn.org/Approval_White_Paper_Final.pdf . National Council of State Boards of Nursing. (2015). 2014 RN practice analysis: Linking the NCLEX-RN examination to practice—U.S. and Canada (Vol. 62). Retrieved March 7, 2016, from https://www.ncsbn.org/15_RN_Practice_Analysis_Vol62_web.pdf . National Council of State Boards of Nursing. (2016). NCLEX-RN test plan . Retrieved March 7, 2016, from https://www.ncsbn.org/RN_Test_Plan_2016_Final.pdf . Orsolini-Hain, L., & Waters, V. (2009). Education evolution: A historical perspective of associate degree nursing. Journal of Nursing Education, 48 (5), 266–271. Reinhardt, A., Keller, T., Summers, L., & Schultz, P. (2012). Strategies for success: Crisis management model for remediation of at-risk students. Journal of Nursing Education, 51 (3), 305–311. Ruby, J. (1999). History of higher education: Educational reform and the emergence of the nursing professorate. Journal of Nursing Education, 38 (1), 23–27. Chapter 2 Principles of Teaching and Learning

An Educator’s Perspective

Vicki Moran

Nursing education requires a variety of knowledge. In my own experience, nursing school did not provide me with the skills to teach in the classroom. However, nursing taught me to make sure that I delivered relevant, evidence-based care to my patients. Therefore, I have learned in my teaching experience, the classroom is like a patient. I have to have certain skills to infl uence my “patient” to deliver relevant and effective nursing care. Inherent to teaching is the understanding that both the educator and the students are learning. While preparation for the teaching experience is completed in isolation, teaching is a collaborative process. Similar to the nursing process, the student or patient is integral to the experience. A variety of nursing theories have been developed and used in nursing education. A theoretical framework is a guide that supports the nursing program. It is developed over time to assist with the identifi cation of graduate characteristics. Your school may even have developed their own theoretical framework which guides the program outcomes. It is imperative that you know your school’s framework because this forms the foundation for every outcome, objective, and learning activity—the entire curriculum. The authors, after an extensive review of the literature, have identifi ed the following principles which are widely applicable to both the novice and experienced educator throughout his or her career. The principles will be utilized in each chapter of this book to serve as guidelines in the analysis of the scenarios and as rationale for determining and evaluating potential actions in each section.

The Seven Principles of Good Practice in Undergraduate Education

The Seven Principles of Good Practice in Undergraduate Education is a well- recognized and practical guide for nurse educators (Chickering & Gamson, 1991 ). Developed by a collaborative effort among researchers, faculty members, and administrators from a wide range of US colleges and universities, the principles are simple, concise, and relevant for nursing education. A table of teaching learning principles is listed below (Table 2.1 ). In this chapter, we will briefl y discuss each one and in subsequent chapters we will use these principles to guide teaching and learning. Principle 1: Encourage contact between students and nursing faculty . The role of the teacher is to facilitate learning rather than to provide instruction. Learning can be achieved in a variety of ways including through student interaction. Therefore, focus your energy on helping students learn rather than providing constant instruction. Recall your positive and negative learning experiences of your own nursing education. Spend a few moments refl ecting on what you remembered and keep them handy. Remember what it feels like to be a student and encourage the student to be engaged in the process. Principle 2: Develop reciprocity and cooperation among students . It is foundational to expect students to know and learn from each other. Nurses on a unit are team players, working interdependently. It takes but a few minutes to think about how many nurses are needed to assist a patient out of bed or in an emer- gency situation, like a code. Therefore, in nursing education, it is important to encourage the students to work together to problem solve and communicate. Principle 3: Encourage active learning . Active learning requires the nursing faculty to explore what this means to students. Active learning in the classroom can lead to a more interactive classroom and many nursing students enjoy the opportunity. However, depending on the group, students who are used to being told everything may fi nd this technique disappoint- ing. Therefore, a nursing faculty member should identify ways that the learning can be active in any setting. For the classroom, this may involve case studies or questions throughout the lecture that the students have to discuss. One example of active learning in the clinical setting is to fi nd the policy or procedure guidelines for a

Table 2.1 Seven principles 1. Encourage contact between of good practice in students and nursing faculty undergraduate education 2. Develop reciprocity and (Chickering & Gamson, cooperation among the students 1991 ) 3. Encourage active learning in all situations 4. Give prompt feedback 5. Emphasize time on task 6. Communicate high expectations 7. Respect diverse talents and ways of learning The Seven Principles of Good Practice in Undergraduate Education 19 particular skill. Active learning supports the natural curiosity of the student and allows more autonomy and direction from the learner. Principle 4: Give prompt feedback . Giving prompt feedback demonstrates respect for students and promotes learning. Often, nursing students spend hours completing a care plan, only to wait two more weeks after clinical is over, to receive feedback or the grade. Students need to know how they are progressing in order to grow. In nursing education, there are a variety of tools used for formative evaluation (during the course) and summative evaluation (at the conclusion of a course) of classroom and clinical. The clinical evaluation tool can be used as a formative and summative evaluation of clinical. In the classroom, examinations are also used. For either of these tools, immediate feedback is helpful for the student’s growth and the development of nursing knowledge and care. Principle 5: Emphasize time on task . Nursing students benefi t from guidance in allocating their time and energy so that these are proportionate to the size and importance of a task. Students think that they should spend 6–8 h on a care plan—an admirable, but disproportionate, effort. Therefore, direction is needed regarding the time necessary for written assignments and even studying. This guidance is helpful so the student can start to understand how much is needed to be successful without using time ineffi ciently. Principle 6: Communicate high expectations . The course syllabus should identify learning outcomes and objectives which specify the necessary expectations of the nursing student. In the course syllabus, evaluative components may include attendance, examinations, and papers. The syllabus serves as the offi cial contract between the student and nursing faculty and identifi es the expectations of the learning experience. A deviation from the syllabus without notifi cation or clarifi cation can contribute to complications in the learning environment. The clinical evaluation tool must also have expectations listed. Students need to understand these objectives in order to apply them to their learning. If there is deviation from what is expected and completed in clinical, there is a confl ict. Students should be made aware early on in the nursing program of the clinical evaluation tool, and clinical faculty should be giving prompt feedback to encourage student’s growth in attitudes, skills, and knowledge of nursing care. Principles 7: Respect diverse talents and ways of learning . This principle seems easy but so often early educators have diffi culty with this. A great example is teaching drug calculations. There are three methods of teaching the calculations. Nursing educators should be teaching all three different ways so the student can understand which one is the best for them to recall and apply. Another common problem amongst nursing educators is the understanding that students learn in a variety of ways: auditory, visual, and kinesthetic. The classroom should have a variety of learning methods to augment the learner. Nursing students, like all learners, bring to the classroom competing interests and infl uence. Acknowledging these infl uences shows respect for the student. This sets the stage for a collaborative learning environment if the educator respects outside infl u- ences and challenging pressures of the educational process. Nursing students often have diffi culty managing school time with work, family, and other pressures. Nursing educators can respect the diverse talents of the students and model a caring attitude in the classroom which can be translated to the clinical setting and patient care. 20 2 Principles of Teaching and Learning

Additional Principles of Teaching Nursing

Many educators teach as they were taught. As a novice nursing educator, there is a need to study teaching as a discipline. In other words, one should gain knowledge on how to teach in a variety of settings. This means reading about educational methods, attending workshops or seminars, and discussing teaching strategies with colleagues in your school of nursing, to gain the best knowledge on teaching skills. Also, consider revising teaching methods for better student outcomes. Teaching is a skill that is best developed over time, but the passage of time alone does not guarantee growth. Excellent educators consistently reﬂ ect on their teaching and look for ways to improve the process to enhance the experience for the nursing student.

• Student Centeredness

All educators can improve from the beginning to the end of their teaching career. Learning to teach is hard work. Excellence in teaching does not develop solely from content knowledge; it takes more than a workshop or an orientation. While excellence in teaching takes many forms, one commonality is a persistent focus on students. The focus of every interaction in the learning environment centers on how the student is engaged and involved in the learning process. Reﬂ ecting on each learning interaction and assessing how the students retained the information aid in teaching excellence. Educators need a constant awareness of how students are experiencing their learning and perceiving the teacher’s action (Brookﬁ eld, 2015 ). While this seems like a very simple principle to follow, one can get caught up with all the content that needs to be delivered. Making sure the student receives the information necessary to pass the course is vital in teaching and learning. However, the instructor’s interaction with the student is paramount. If the student does not feel like he or she is important, the teaching and learning process suffers.

Scenario One: Student Engagement

Ben was attentive in class and was engaged in the classroom discussion. He was prepared for class and was getting anxious about clinical and the paperwork that was necessary to complete. He made several appointments to meet with Monica, the clinical faculty. After the third appointment, Ben told Monica about his fears of caring for a patient, focusing on the idea that he had no idea what he was going to do at clinical. Monica slowly and confi dently explained to Ben the exact movements of the clinical day such as completing the physical assessment, facilitating a bath with the client, administering medications, and completing charting. Ben wrote down the expectations. She then explained to him that all of the skills that were necessary for the day had Refl ective Practice 21 been completed in the classes he was currently taking and ready for implementation in the clinical setting. After the meeting, Ben was relieved as she had explained and showed him what had been learned and how it was applicable to clinical. Key Issue : The student needed validation of what had been learned. By taking the time to show the student what has been learned, a more collaborative approach is used. Often students have diffi culty connecting how learning is applied. Clinical is one area where the skills and assessment techniques taught can be applied. The student is the focus and often times need validation that they are on the right path to becoming a nurse.

• R e ﬂ ective Practice

Teaching is a process, and for even experienced educators it evolves and changes over time. For one to become better in the classroom, teaching should be evaluated by the teacher and the student. Brookfi eld (2015 ) states that a skillful educator refl ects on their teaching ability and adapts a critically refl ective stance toward their practice. By evaluating decisions and actions in the learning venue, an educator can become more engaged in their teaching ability. Refl ecting on teaching practice can cause a variety of events to occur. First, a teacher can be energized by the refl ective practice to constantly look for ways to improve classroom teaching. Mindful teaching becomes a practice grounded in an awareness that things are rarely as they seem (Brookfi eld, 2015). Second, by refl ecting on what one has completed in the classroom, educators are role modeling the ability to critically refl ect on actions. Students can then in turn feel safe to evaluate their own actions. Finally, critically refl ective practice refreshes the teaching environment. By being alert to new ideas and challenges, faculty can implement new ways of delivering content and actively engaging the student.

Scenario Two: Reﬂ ection

Most schools of nursing allow and encourage students to evaluate courses and clinical settings. Margaret was reading her student clinical evaluations and was preparing a report to share with the other clinical faculty who taught in the same course. Many of the students commented on how accessible the head nurse was on several of the clinical days when the students were present. The students commented on how the head nurse was kind and informational about patient care issues and assisted the students in care when Margaret or the primary nurse of the patient was unavailable. Margaret refl ected on what this meant to the students and summarized the comments in the clinical faculty debrief meeting. Key Issue: The message is that the students were able to see the value and expertise of the nurse manager engaged in patient care. Margaret should also 22 2 Principles of Teaching and Learning share this information with the coordinator of the program and the nurse manager of the division where clinicals were performed. By having a manager involved in patient care while the students are present refl ects excellent role modeling and collaborative care. Margaret’s refl ection and dissemination of the student observation of the nurse manager show inherent growth to praise others for exceptional work. She is refl ecting and identifying behavior that is necessary for her growth as an excellent educator. This is just one example of refl ective teaching practice.

• Teaching Philosophy

A good educator also examines his or her assumptions and beliefs about teaching and learning. Developing a teaching philosophy is another technique to improve teaching excellence. An easy technique to develop your teaching philosophy is refl ect on one educator that infl uenced your own learning. Then answer these questions: How did they infl uence you? What did they offer in the classroom that was helpful? How did they make you feel as the student? These questions develop the foundation of your teaching philosophy. Often times, an educator can be also infl uenced by other educators. Learning from others, from educational classes, and from professional development seminars can also assist in building a strong teaching philosophy. Educators role model teaching techniques and skills are often learned from other educators. Focusing on one’s own personal infl uences assists in developing a teaching philosophy.

• Team

A team of educators provides a skill mix that can be collaborative in nature. Working as a team can be helpful for new educators. Insight and direction from experienced educators can guide the new instructor to see the value in the content, assist in delivery of materials and the organization of the course. This approach is valued as it can assist in the transition of a newer instructor using role modeling. Also in this approach, a newer instructor can feel supported as they learn a new skill set in the classroom setting. An example of a team approach is where content is divided between the educators and each educator prepares, delivers, and prepares test questions on their content. The educator may be responsible for two of the ten classes to teach the content assigned. Another example is where all team members attend all class sessions and assist the lead instructor by providing comments and insight about the content. Learning Environment 23

• Vulnerability

Inherently, there is a notion of vulnerability with any new learned skill even with teaching. Vulnerability is the state of being open to injury. Teaching is a learned skill. As educators, we grow comfortable a little more with ourselves, our knowledge, and our ability to teach in the classroom or clinical setting each time we teach. There are three inherent truths about students which impact the vulnerability factor. First, nurse educators possess valuable knowledge from their practice. Educators teach because we care about patient’s fi rst and then translate this care to the classroom. We have to come to the realization that we have sound evidence and expertise and we will guide the class to learn. Second, it is not possible to force students to engage in the classroom. No matter how much we give to the classroom environment and provide active learning, we may fail and fail miserable. Ultimately, it is the responsibility of each individual student to learn by engaging in the classroom. Educators facilitate learning but cannot force it to happen. Third, motivation for learning has to come from within the student. Engagement and motivation are different. No matter how much we give to a class, there will be students who are not motivated. This should prompt refl ection by the educator to think about the various ways to engage and motivate. Neglect by the student in either of these areas does not necessarily indicate failure by the educator. The vulnerability factor is often infl uenced by student evaluations. It is imperative that educators review the evaluations in light of the three inherent truths presented. Educators are especially vulnerable during the fi rst few years of teaching as they tend to personalize all evaluations and fi nd reasons to leave teaching. Remember that teaching is a process and the more one learns about their own teaching philosophy and themselves, the more confi dent and easier teaching becomes.

• Learning Environment

An educator should foster a learning environment that is characterized by trust, respect, helpfulness, freedom of expression, and acceptance of differences that allows the nursing student to feel safe and to ask questions. This also sets the stage for the educator’s role as the facilitator of learning. Active learning is encouraged in this environment and nursing students will be able to grow in this new role. Problem- centered learning promotes an active engagement of the nursing student. The case studies, simulation, and clinical become a learning environment where there is constant interaction of the nursing student and faculty. Learning is constantly occurring. Above all, educators must be role models for the characteristics that we expect from our students—lifelong learning, civility, and caring. 24 2 Principles of Teaching and Learning

Scenario Three: Learning Environment

Kelley was teaching a pharmacology class. This was her fi rst semester of teaching this class. The students completed 6 examinations during the course. After each examination, Kelley would review the questions. This is the same way the previous faculty member had conducted the class. After the second exam, she was reviewing each test item. One of the students challenged a question and after being frustrated with the student comments, Kelley told the student that they were right and accepted another answer. Later, Kelley was sharing the student with the experienced faculty member and the faculty member told Kelley that she should not conduct a test review and take any answers other than those identifi ed. The faculty member stated “It sends the wrong message that you are wrong and they are right.” Kelley refl ected on this message. Key Issue : Kelley was attempting to create an atmosphere of learning. She was learning from the perspective of the student by listening to the rationale of the exam item. Kelley was not wrong in doing this and it does promote a collaborative environment. However, the faculty member is also right as accepting another answer alerts the students in the ability to “sway or bully” the faculty member. As stated, a learning environment should be conducive for student learning. Some of the students from the example will come to realize that the faculty member cares about what the students are thinking as well as how they are learning. Both Kelley and the faculty member are correct. Kelley presented an idea to the students that she cared about them. However, Kelley also needs to be mindful that she is the expert and the students can weigh in on questions, but the faculty needs to be explicit on explaining the correct answer and providing the right information in the classroom setting.

• Adult Learners

Students attending nursing school are considered to be adult learners. Adult learners are quite different from child learners. Adult learners have acquired specifi c skills during their life experiences. Their life experiences have added to their sense of social responsibility, and they have identifi ed that acquiring more knowledge is helpful for their life journey. This means that adult learners have decided to make a con- scious decision to acquire more knowledge. They use their own self-direction and autonomy to venture into acquiring more education. Andragogy is the theory and practice of educating adults. It is the science of understanding and supporting lifelong education by adults. Malcolm Knowles, one of the most well-respected experts on andragogy, identifi ed fi ve characteristics of an adult learner (Knowles, 1980 ). 1. Self-concept: Adult learners have a more fully developed sense of self than younger learners and this leads to increased self-direction. Self-direction exists when a learner understands what they need to gain knowledge. Learners are self- directed in learning. The educator should collaborate with learners by eliciting their input and encouraging them to set learning goals, identify their learning Adult Learners 25

needs, and take initiative for their learning. The educator can also motivate learning by balancing positive and constructive feedback. 2. Experience: A learner develops a meaning of knowledge by using his or her own experience. Faculty must recognize that some previous life experiences can facilitate learning while others may interfere with learning. Not all nursing students come from one background. Diversity exists in the nursing student population, today more than ever. 3. Readiness to learn: A learner understands their own readiness to learn based on their role in society. Nursing students are eager to learn nursing. The educator should demonstrate enthusiasm for the content and most nursing students will follow suit. 4. Orientation to learn: A learner who is oriented to learn applies knowledge that has been acquired and uses it to solve problems. A learner develops a deeper understanding through application of knowledge. 5. Motivation to learn: A learner develops a deeper motivation to learn as they grow and mature. Adult learners bring life experiences that impact their ability to see concepts clearly or understand processes cohesively. Therefore, nurse educators should be prepared for learners that have a variety of issues and distractions from the educational process. Caring for children, employment, or caring for an ill partner or par- ent can distract the adult learner from fully engaging in the educational process. Adult learners provide insight and motivation. They are dynamic and interesting and feel comfortable challenging the educator. The insightfulness of the adult learner should be reﬂ ected on and used to create a positive learning environment.

Scenario Four: Developing Reciprocity and Cooperation in Students

Mary had gotten married in her early twenties and attended 2 years of college. She had three children and her youngest was a sophomore in college. She was sure about returning to school to earn her nursing degree. After careful analysis, she decided the easiest road was going to the local community college to complete her associate’s degree in nursing. After 1 year, she applied to the nursing school and was accepted. Sitting in her fi rst nursing course with Suzanne, a seasoned faculty member, Mary was nervous. She looked around and saw other students much younger than herself. At the end of the 2-h lecture, Mary approached Suzanne, smiled and asked if she had time to meet. They immediately walked to Suzanne’s offi ce, where Mary explained her background and tearfully admitted she was not sure she should complete this nursing degree. Key Issue: The is a common issue with students who return to school after having life experiences and realizing they want to pursue something different. The student brings to the educational environment diverse talents from her life. The student 26 2 Principles of Teaching and Learning needs to take a moment and refl ect on why she was going to nursing school. She should be encouraged by the educator to reach out to other students in the classroom and develop relationships with the other students. This aligns with Principle 2: developing reciprocity and cooperation among the students. Remind the Adult Learner Why They Are Doing This . Suzanne offered Mary a tissue and asked her why she wanted to become a nurse. Mary’s tears were soon placed with enthusiasm about her life as a mother and caregiver of some of the elderly residents in her neighborhood. At the end of the conversation, Suzanne was able to recenter Mary’s thoughts back to her desire to become a nurse. Adult students, because of age, often think they cannot complete their nursing degree. Sometimes it is a moment of lapse for the student in the immediate thinking that they cannot complete the course or the program. Faculty should be prepared for this and allow time for the adult learner to think about how the educational process will benefi t them. Adult learners are driven but at times get lost and need direction. Faculty can provide support and facilitate the learning process of the adult learner.

Conclusion

Teaching is an art. Nursing is the science. A meshing of these creates a teacher who is dynamic, interesting, and willing to listen to students. By using the principles in this chapter, a nurse can become a dynamic educator. The nursing profession needs excellent educators to teach the art and science of nursing.

References

Brookﬁ eld, S. (2015). The skillful teacher (3rd ed.). San Francisco, CA: Wiley. Chickering, A. W., & Gamson, Z. F. (1991). Applying the seven principles for good practice in undergraduate education . San Francisco, CA: Jossey-Bass. Knowles, M. (1980). The modern practice of adult education . New York: Cambridge. Chapter 3 Classroom Teaching

An Educator’s Perspective

Keeley Harmon

When I began my teaching career, I was assigned to a faculty mentor for an entire semester. I was to observe her in the classroom and clinical settings. Things seemed to be moving along smoothly and I was learning much during my observations, both positive and negative. But then there was that day. The dean emailed me and asked me to come to her offi ce as soon as possible. Of course I went directly there without hesitation. When I entered her offi ce, she began to tell me what a great job she thought I was doing and that she thought I was ready to come out of orientation. It seemed that they needed a faculty member to teach the second section of the medical-surgical course (at this particular institution, the cohort was divided into two sections and the medical-surgical course was provided twice during each semester to accommodate both sections). I felt split between what I wanted to say versus wanting to sound positive and willing to do anything for the institution as part of the academic team. One thing was for certain, I did not feel ready, by any stretch of the imagination, to manage and teach a course completely by myself. After orienting with this faculty mentor, I quickly realized that I would be 100 % alone. However, I told the dean that I would be willing to take on this assignment and that I appreciated her confi dence in me. As soon as I left her offi ce, a sense of dread fell over me. I did not know the fi rst thing about preparing the course and I barely knew how to navigate the learning management system (Moodle). I had 1 week to prepare the calendar and my lectures! I went to my mentor’s offi ce and asked if I could please use her PowerPoint presentations for my lectures, given that I would not have much time to prepare them. Unfortunately, she told me that she did not share her PowerPoint slides. I quickly felt like I was drowning and I had wished I had spoken up for myself. But now it felt too late to go the dean as I knew I would be viewed as having a negative attitude.

I remembered speaking to a faculty member who stated that she had previously taught this course and if there was anything I needed, she told me not to hesitate to contact her. I decided to take her up on her offer and she was more than happy to let me use her lectures. She emailed each of them to me within an hour. That was such a relief for sure. Now I just needed to review them and make sure I was able to dialog about the content. The other thing I was not prepared for was the number of emails that students sent stating anything from “I have to miss an exam because I am in a wedding” to “I want to switch clinical groups” (we were also clinical coordinators as well). Though I do not remember what decision was made about many of those situations, I do remember vowing one thing—I would always display a caring approach to my students. And that approach has paid off to this day, 12 years later. Undoubtedly, policies have to be followed or students will run amuck. But I have always felt that if you treat students like human beings, you can still hold them accountable while still telling them no or yes when indicated. The purpose of this section is to provide information and scenarios that are commonly encountered in the didactic (or classroom) setting. Information regarding best practices is presented. Each scenario will be followed by the key issue along with practical solutions based on best evidence.

Scenario One: The Basics

Jane has been a family nurse practitioner for the past 25 years. Her role was demanding and required many nights on call. Recently, she accepted a position as a nurse educator, needing a job that afforded her more fl exibility and more time at home with her aging father. When she was hired at this large baccalaureate nursing program, she was immediately assigned to the junior level medical-surgical course. The other faculty member assigned to the course was also new, with no true teaching experience. Both of the faculty recalled feeling like they were “fl ying by the seat of their pants.” The two quickly banded together and decided they would fi gure it out. Faculty in the courses above and below them decided to help them by providing their syllabi for them to use as a guide. Neither Jane nor her colleague understood much of the academic jargon spoken (e.g., program outcomes, unit level outcomes, course outcomes, etc.). To make matters worse, they both received only a cursory introduction to the learning management system, Moodle. With 2 weeks to go prior to the beginning of the course, they were both struggling with where to begin. Key Issue : These two faculty are contending with an increasingly common scenario: many faculty are entering into the academic setting with no teaching experience. They are faced with new responsibilities and course preparation activities such as writing a syllabus and interacting with the learning management system. The purpose of this section is to provide important information that pertains to some of the most common areas that new educators will encounter. The teaching and learning principles, presented in Chap. 2 , focus on the student needs or student centeredness and the learning environment. The faculty need to center on what is necessary in this course, its position in the curriculum, and the learning level of the student. An Educator’s Perspective 29

Syllabus Preparation. The syllabus is the most important course document. The purpose of the syllabus is to provide an outline or summary of the information required for the course. It is considered a contract between the student and the faculty. The syllabus usually contains course objectives, course content to be presented, and methods of evaluation like tests or written assignments. The syllabus also contains additional information such as the textbooks and other reading materials assigned to the course, course policies, and a course calendar. Information in the syllabus cannot be changed without proper vetting according to institutional policy. A thorough, clear syllabus fulfi lls Principle 6 of the seven principles of undergraduate education as it communicates important expectations related to student performance (Rotenberg, 2010 ). Prior to the beginning of the semester, it is crucial that the faculty ensure that all information presented is accurate. Experienced nursing educators know that if information is inaccurate in the syllabus (such as outdated textbook, incorrect faculty contact information, or invalid grading procedures), it causes the students great dis- tress and they begin the course with mistrust for the faculty. Many institutions require courses to follow the approved syllabus template and often there is information contained in this template such as course-specifi c information (name, prerequisites/ corequisites, credit hours), course learning objectives, faculty information (contact information, credentials), grading scale, course evaluation (what is graded and how), and specifi c course policies (missed exam/assignment policy, academic integrity, technology requirements, especially if testing on computers) (see Appendix A). A good, thorough syllabus does not need to be 20 pages in length. Students will get lost in the minutia and will not pay attention to the important aspects. Some of the policies embedded in the syllabus may be better suited for the Nursing Student Handbook. Remember, the syllabus is a document that is intended for students to read. When it is too long and cumbersome, students tend to overlook the important information. Many schools require students to acknowledge in some fashion (by an acknowledgment online or by signing a form) that they have read and understand the syllabus. Regardless of whether acknowledgment is in writing or not, the syllabus is a binding contract between the student and faculty. Any changes to the syllabus should be communicated in various forms: email, handouts, and announcements so that students have ample amount of time to know what is expected of them. The syllabus sets the stage for the culture of the course. Specifi cally, the wording within the syllabus can inform the students of the caring attitudes of the faculty teaching the course. Words such as “I want to help you” and “Please come to my offi ce if you need additional assistance” can serve to provide the students a sense that the educator is truly concerned about students’ success (Harnish & Bridges, 2011 ; Perrine, Lisle, & Tucker, 1995). This language also aligns well with the principles of good practice in undergraduate education discussed in earlier in Chap. 2 . Canada (2013 ) discusses the fact that a syllabus written in a more friendly tone will “leave students with more positive feelings toward the professor” (p. 38). Other strategies included by Canada (2013 ) include: • Using plain and direct language. Using “you” frequently “reminds students of their role in the course” (p. 38). • Demonstrating humility. Many faculty have been in nursing for a number of years but it is important to remain humble with the students. Canada (2013 ) uses 30 3 Classroom Teaching

the example of “I’m with you. In fact, I used to be you” (p. 38) as an appropriate statement inserted in the syllabus. • Inserting a comment at the beginning of the syllabus such as “I want each of you to succeed” (p. 38). Such statements can diffuse tension and can enhance the environment for optimal learning. Course Objectives (Outcomes) . As discussed above, information in the syllabus cannot be changed without proper committee/Nursing Assembly vetting. The course objectives or outcomes (terms used interchangeably) are an important inclusion in the syllabus and changes must be approved by the Curriculum Committee and then by the appropriate committee which represents the full body of nursing faculty. Course objectives/outcomes are the expected results of teaching activities. They are also instrumental to the foundation of assessment, either by use of testing or another measure. The objectives should be written to drive the cognitive, affective, or behavioral direction of the student and should progress in complexity from the beginning courses in the nursing program to the senior level courses. The program level outcomes represent a picture of what the school hopes the student will accomplish at the time of program completion. Appendix F illustrates an example of program outcomes. It is important that the program outcomes are written in a manner that are measurable and the school can effectively describe how the program outcomes are accomplished. Many schools distribute employer satisfaction surveys that assess the graduate’s performance following graduation (usually at least 6 months following graduation). Developing the Course Lesson Plan —Fitting It All Together. After reviewing the course syllabus for accuracy, it is time to focus on preparing the class sessions. When preparing to deliver the content, it is important to develop a lesson plan. Table 3.1 illustrates an example of a lesson plan. Please keep in mind that each school may have a slightly different presentation. Since the examination blueprint and development of NCLEX style questions are discussed in the table, it is important to emphasize a crucial point. It takes a long time for one to develop into an effective item writer, one who can develop items that truly assess student learning. It is not within the scope of this book to delve into effective item writing (that is a book in itself). New educators are encouraged to attend as many item writing workshops as possible. It is highly recommended that item writing at any institution not occur in silos. Each nursing program should have an item writing committee or task force that provides feedback on test items on examinations. Another recommendation is that faculty as a whole should spend a couple of weeks out of the summer months (ideally when school is not in session) in item writing sessions. Examination items in test banks should simply not be con- tinuously recycled. Be careful of overuse of test banks from books. Instances have occurred when students have “posed” online as faculty and purchased test banks. Faculty also hold a false assumption that students do not reconstruct examinations. The Learning Management System (LMS). For the classroom setting (the use of the LMS is described in more depth in Chap. 6 ), the LMS serves as a placeholder for resources, activities, and student grades. It also serves as a communication tool between students and faculty. Each institution usually has speciﬁ c parameters/ An Educator’s Perspective 31

Table 3.1 Example course lesson plan Evaluation (How Learning will I assess Program objectives for student outcome or course (listed in Unit level learning Teaching knowledge competency the main course outcome (posted for learning acquisition for category syllabus) each class session) strategy each activity?) Graduates will Oxygenation— Oxygenation— Prior to Post-quiz demonstrate student will gain student will describe class : Class discussion critical an understanding the pathophysiology Read pages of the case studies thinking and of oxygenation in related to chronic 210–217 in NCLEX style clinical relation to chronic obstructive your question on unit reasoning disease processes pulmonary disease assigned examinations skills to make textbook patient- (you can centered care add the decisions name of when caring the book) for patients Pre-class across the quiz lifespan In-class activities : Review quiz results Students will work in groups to review case studies and answer questions related to case studies Class discussion of case studies a Faculty should post in addition to the course syllabus and lesson plans, a course calendar that includes a blueprint of examination items (the number of test questions that correspond to each lecture). Please see Appendix C (Exam Blueprint) for an example templates that are to be followed with the course development but often times this is not communicated. It is usually wise to schedule a meeting with the Instructional Technology (IT) liaison at the school in order to review specifi cs related to the development of the topics within the LMS. You will probably fi nd that there are multiple ways to present information to the students on the LMS. But it is important to adhere to sound education principles when posting and presenting information. The classic example is when three supplemental articles and a PowerPoint presentation are posted and students are 32 3 Classroom Teaching expected to have read everything prior to class. It is easy for faculty to get excited about what they are teaching any given week and, in that excitement, faculty may want to post supplemental information for students to review. Remember that in many cases, students are also preparing for clinical, simulation, and whatever other courses they are taking. Another thing to consider is that often times IT will copy course shells from semester to semester. When copied, students will be able to view each topic area utilized from a previous semester. Therefore, it is important to be aware of when IT will be copying the courses (often times you are not told). To prevent students from viewing outdated information, faculty need to “close the eye” for each topic area until you are able to review for accuracy. Also, it is necessary to go into each assignment and change the due dates, since those dates are copied over from each semester. It can be very frustrating to students when they are told by faculty that an assignment is due and they cannot upload the assignment because the date settings are incorrect. What Are the Nuts and Bolts for Preparing for Class?. Much of this information is provided in Table 3.2 (Example Course Lesson Plan). Step 1: Locate the learning outcomes/objectives for the course. These may be found in the syllabus that was designed for this course. If learning objectives for the course are not available, contact the mentor/director for guidance to where the objectives are listed. All nursing programs must submit annual reports to the State Boards of Nursing with a list of the learning objectives for each course. Step 2: Locate the unit level learning outcomes. These outcomes describe the specifi c topics that should be presented during the designated class time. Step 3: Ask the mentor/director or other faculty members for assistance in locat- ing teaching and learning outcomes and resources. Step 4: Contact the textbook/ebook sales representative for assistance in locat- ing faculty resources. Important: Ask for training on how to use the resources! Most of the resources can be accessed electronically. At times, as peers may not have used the resources recently or have developed their own, contact the textbook help desk. Step 5: Evaluate: What teaching resources are found most valuable? Which of these would promote student-centered learning? Which would promote an active classroom?

Table 3.2 Example pre-class assignment List each unit objective: List the activity associated with the unit objective: 1. Describe the pathophysiology of 1. Read pages _____ to ______in (list textbook Diabetes Mellitus here) 2. Describe the possible pharmacologic 2. View the online 10 min presentation interventions for patients with Type I describing the pharmacologic interventions. and Type II Diabetes Fill in the table with the medications 3. Etc. 3. Etc. An Educator’s Perspective 33

Scenario Two: Classroom Engagement

Sherry recalled entering into the classroom for her fi rst time following a semester of observation. She attempted to utilize many of the strategies that she had observed, including case studies, group activities, and lectures. Because the topic for this particular day was diabetes mellitus, she discussed the different types of insulins for patients with type I and type II diabetes and described potential adverse reactions and side effects. The students then engaged in a case study that involved a patient who was scheduled for surgery and was NPO except medications. The surgery was scheduled later in the day and the patient was scheduled to receive several medications (including all insulins, both long acting and short acting). The goal of the activity was that the students should verbalize that the patient should not receive the short-acting diabetic medications and clarifi cation should be sought regarding the dosing of the sliding scale insulin. When it came time to discuss the case study, Sherry was met with blank stares and what she described as “a full classroom catatonic state.” No one would answer any questions and there was absolutely no engagement on the part of the students. Key Issue: It is not uncommon for an educator to feel as if she has done her best to get the students’ attention in class and engage them in a meaningful learning experience. It was described earlier that millennials and Generation Y students need to be constantly engaged and, if they are not, they rapidly lose interest. The key issue is determining methods to effectively engage students in the classroom and thus fulfi ll Principle 3 of the Seven Principles in Undergraduate Education related to encouraging active learning. First Refl ect on Our Beliefs About Teaching and Learning . Before changing teaching methodologies, it is important to refl ect and ask a few key questions regarding why students may not be engaged in the classroom: 1. Do I look engaged myself? It sounds obvious, but in order for students to engage in the classroom environment, they must feel the excitement from the faculty. An established mantra is: teach three concepts really well! It is not that other concepts will not be taught; however, if one has effectively taught three ideas, the experience has been successful. I will usually start class off with… “these are the three things that I want you to REALLY learn today: ….” Then at the end of class the students write down a short evaluation which includes: what three things did I learn today, what do I need clarifi cation on, what I liked about class, and what I did not like about class. This is called a 2-min evaluation and it is extremely effective. If students note something that is repeatedly unclear, post clarifi cation on the LMS. 2. Am I just reading off of the PowerPoint slides? The use of PowerPoint presentations in lectures was groundbreaking 15 or 20 years ago and seemed like a valuable alternative to transparencies. In fact, students have learned to depend upon them in class. What I hear from students anecdotally is that when faculty lecture 34 3 Classroom Teaching

and read off of the PowerPoint slides, students lose interest quickly. What students truly want to hear about are faculty experiences in the real world of nursing. 3. Do I feel like students need to know everything? Most, if not all, nursing faculty have specifi c content areas for which they are particularly passionate. This positive attribute can cause the faculty to teach more than students need to know at a particular level and perhaps more than is contained in the syllabus and content outline. This can lead to content overload in a curriculum that is already over- saturated (Giddens & Brady, 2007 ). It is imperative that faculty strive to ensure that content is current and that what is taught in class adheres to what is outlined in the course syllabus and content outline. If faculty are concerned that there are gaps in the content for a particular course, then a recommendation for change should come from the course faculty to the Curriculum Committee. So How Do We Engage Our Students? According to Wiedmer (2015 ), this generation of students prefers to be taught online rather than in a lecture style setting. This presents both challenges and unique opportunities for educators. Course evaluations confi rm that educators are being challenged to detach themselves from the comfort of reading the PowerPoint slide and branch out into other, more student-centered approaches. Faculty are familiar with “active learning” strategies, which are meant to remove faculty from being the “sage on the stage” and be more collaborative with students in their learning. It is easy to use this term and requires that faculty use more active learning strategies in the classroom. However, without providing faculty with the resources and ongoing development regarding the faculty role in the utilization of the chosen active learning strategy, the learning session is no more fruitful than putting up a PowerPoint slide and asking students to take notes. The fl ipped classroom is one active learning strategy that is gaining momentum as a successful method to enhance student learning. An explanation of the fl ipped classroom and a fully developed lesson plan that can be utilized for practice is discussed below. Try this example for a semester with the content and refl ect on strengths and areas of opportunities. Remember, Brookfi eld (2012 ) embraces the concept of trying out different strategies and permitting oneself to both be successful and to realize that changes need to be made. Let the students’ feedback be a guide for revisions.

The Flipped Classroom

What Does the Term Mean? According to Hawks (2014 ), “the fl ipped or inverted classroom provides opportunities for advanced preparation and time to identify knowledge gaps needing clarifi cation” (p. 265). Faculty provide students with a pre- class assignment and students come to class in order to seek clarifi cation regarding the content, and faculty can provide relevant real life examples to allow for a deeper understanding of the content. Students can also work together in groups during class to solve problems, which allows for a rich experience working with peers. The Flipped Classroom 35

Hawks (2014 ) presented studies that illustrate student satisfaction with the ﬂ ipped classroom experience. Two characteristics promoted student satisfaction with this model: explanation of the rationale of the practice and pre-class assignments that were not too overwhelming and took into account the workload of the student. Faculty should spend time during class orientation explaining that the ﬂ ipped classroom methodology will be utilized during the semester and that the literature indi- cates that use of this strategy enhances critical thinking and retention of the material. Faculty should make a promise to the students that the pre-class assignment will be posted at least 1 week in advance and will take into account all other workload requirements. Students are encouraged to forward questions that develop while completing the pre-class assignment. Table 3.3 provides an example of the pre-class assignment for diabetes mellitus. The setup for the classroom can be an important aspect of active learning. Stadium seating is not ideal for this type of learning environment, but it can be successful. The ideal setting for the active learning environment is a room with white boards or writing surfaces around the room and with tables set up in such a fashion that will promote group work. The class size will drive the number of students per group; however, it is best if there are only four students per group (no more than six). Tables should be set up such that students will face each other. Roles should be assigned: recorder (note taker), leader (leads the discussion and engages the unen- gaged by asking questions such as “what are your thoughts”), reporter (reports to the larger group), and observer (observes group dynamics and discusses involvement of the group). If this strategy is implemented throughout the curriculum, students become accustomed and comfortable with group work. The group member roles should be discussed at some point in the curriculum and reinforced in each course (preferably during orientation).

Table 3.3 Example in class activity 1. Question and answer session: At the beginning of each in-class For each activity, state session, faculty discusses student questions submitted prior to the approximate class. This provides faculty and students with an opportunity to time assess individual student knowledge gaps 2. In-class quizzes: At the beginning of each new unit, administer a short quiz to assess students’ beginning knowledge of the content area. Frequent quizzes provide students and faculty with immediate feedback and identify existing knowledge gaps 3. Interactive learning activities: a Case studies: Student groups are directed to examine speciﬁ c aspects of the same or different case studies. Results are shared among all groups and answers are critically reviewed. Students obtain practice in responding to corrective feedback and provide rationale for individual decisions Group presentations: Groups develop presentations on speciﬁ c topics that are extensions of pre-class content. Students’ writing skills and the ability to translate evidence to practice are developed a Example case study is provided in Appendix D 36 3 Classroom Teaching

One of the most important aspects of the fl ipped classroom is the evaluation of student learning. Multiple strategies should be used to assess student learning, including quizzes, case studies, short answer, etc. (NLN Fair Test Guidelines, 2010 ). Nurse educators are driven by this notion that we must at all times be preparing students for the NCLEX-RN examination and, therefore, NCLEX-RN style examinations are the only effective means for true NCLEX-RN preparation. This discussion is beyond the scope of this book; however, we challenge schools to begin the conversation directed toward a thorough review of the literature examining the nature of effective evaluation of student learning. For the purposes of evaluating student learning in the fl ipped classroom, multiple strategies should be implemented to better understand where gaps in learning exist. Whichever teaching method is used in the classroom, it is imperative that faculty take the time to refl ect on feedback. It is highly recommended that faculty use the 2-min evaluation at the end of class in order to provide the faculty with quick feedback regarding the teaching approach. During the 2 min evaluation, it is helpful to ask questions such as: What did you like? What do you need clarifi cation on? What did you like least? If students are commenting consistently on a particular content area, one may need to go back and review that content. Brookfi eld ( 2012 ) clearly stated that faculty should not be afraid to fail. As faculty, we will have days in the classroom where the approach caused a lot of light bulbs to turn on (so to speak) and there will be days where we will be met with nothing but blank stares. Faculty should also take their end-of-course evaluations and review the student feedback. Most schools conduct evaluations of each faculty member and the course overall. The faculty should review their individual evaluations and refl ect on them in order to make changes on teaching practices. The course faculty should meet to review the overall course comments. Minutes should be taken during the end of semester meeting and there should be documentation of the plan to address the comments. Be mindful that teaching is a process and the educator learns more over time about themselves and how to teach students.

Scenario Three: Helping the Student Who Is Failing a Nursing Course

Gabby was a good student who performed exceedingly well in her nursing prerequi- site coursework (pre-nursing overall grade point average = 3.8). She is a fi rst- generation college student (fi rst person in her family to attend college). When she started the nursing program, she had no idea what to expect and really did not have anyone to go to in order to fi nd out what she should be doing to prepare herself for what was ahead. She had no choice but to work while in nursing school and she found herself quickly in trouble. Midterms proved to be a problem, and Gabby was earning a D in her anatomy and physiology course. She met with the anatomy and physiology teacher every day and was attending tutoring, but she had gotten a D on the midterm. She also had a C in her general statistics course as well. She was scheduled to meet with her nursing faculty advisor, Dr. Holt, for the fi rst time after midterms. The Flipped Classroom 37

Key Issue : What is described in this scenario is unfortunately a common occurrence in nursing education programs. Students begin the nursing program unaware of the intensity and rigor of the curriculum. Many are under a false assumption that nursing school is similar to their pre-nursing coursework and, if they made good grades in those courses, then they will likely be successful in nursing school. This is coupled by the growing population of students that must work while in school in order to pay for their tuition. Two key principles should be considered for this scenario. Principle 1 encourages contact between the student and faculty. This allows the educator to encourage communication and interaction during the education process. This process can set the tone that the educator is here to help the student succeed in the process. Principle 6 aims to communicate the high expectations that are held of the student. The students need to understand what is expected of them while a student in the nursing program. Strategies for Faculty in Facilitating Student Success and Promoting Student Retention . There are a variety of factors impacting student retention in nursing programs and it can be quite challenging for schools to identify the reasons for a decrease in retention. Multiple models exist to provide a framework for analyzing student retention, and the model chosen for this discussion is the Model of Nursing Undergraduate Retention and Success (NURS). This model, as proposed by Jeffreys (2012 ), presents factors that contribute to student attrition and retention such as academic factors (study skills, study hours, attendance, class schedule, general academic services), professional integration factors (nursing faculty advisement and helpfulness, professional events, memberships, encouragement by friends in class, peer mentoring–tutoring, enrichment programs), environmental factors (fi nancial status, family fi nancial support, family emotional support, family responsibilities, child care arrangements, family crisis, employment hours, employment responsibilities, encouragement by outside friends, living arrangements, transportation), psychologi- cal outcomes (satisfaction, stress), academic outcomes (course grade, cumulative nursing GPA, overall GPA), student profi le characteristics (age, ethnicity and race, gender, etc.), and student affective factors (motivation, etc.) (p. 12). The model is quite extensive and insightful regarding aspects of programmatic, faculty, environmental, and student characteristics impacting success. For the purposes of this scenario, the strategies that faculty can undertake to enhance student retention and success are outlined below. 1. Faculty advising. Faculty advisement of nursing students is a skill all in itself. The goal with advising should not simply be to enroll students in their next semester courses; rather, faculty should be assigned to students newly enrolled in the nursing program. An excellent proactive measure to enhance student success involves reaching out to these students prior to the start of their fi rst semester in the nursing program with a letter of welcome ( Appendix E). This letter of welcome encourages the student to schedule a meeting with the faculty advisor in order to discuss key elements of strategies to be successful in nursing school. This session can serve as a means to dispel frequently heard myths about nursing school and can provide students with key tools of success (i.e., study strategies, test taking strategies, stress reduction strategies, etc.). Appendix F outlines key discussion points during the meeting with the student. 38 3 Classroom Teaching

2. Discuss success strategies related to the course being taught. Prior to starting each new course, faculty typically review the course syllabus during the course orientation session. This is a wonderful time to discuss the key strategies for success in the course. Also, faculty should state that they care about student success and that they want students to notify them with questions, concerns, and when they need clariﬁ cation on the subject matter. It is also beneﬁ cial if faculty state in the syllabus that students must meet with them if they score a certain grade on the unit examination. For example, our passing course grade is a 77 % and students must meet with faculty if they make below an 80 % on an individual course examination. We can review the examination items and this is a good time to review test-taking strategies. In order to accomplish this objective, we divide the students into groups and assign the course faculty to each group. Students know which faculty they should contact for any course-related issues. The course faculty should also discuss any issues that arise with the course coordinator.

Scenario Four: Incivility in the Classroom

Clara has been the primary faculty and course coordinator for the past year in the Fundamentals of Nursing course. For the upcoming semester, nursing administration decided to implement team teaching in all of the nursing courses. With that, faculty are required to “teach together” at least three times during the semester. During this “teach together” time, one faculty was to serve as the lead faculty during the scheduled class time (notice I did not mention the word “lecture”) and the other faculty was to observe and provide peer review. Clara was paired with a faculty member (Rhonda) who has a reputation of negativity. On the fi rst day of the semester, both faculty were in the classroom together. Several students walked into the classroom anywhere from 10 to 20 min late, and Rhonda consistently commented in a rather loud fashion that “we have got to get some rules established in here right now.” Clara, a calmer, more nurturing faculty member, planned to discuss the expectations of the class and found herself feeling angry that Rhonda took over and overwhelmed the classroom with such negativity on the fi rst day. Rhonda felt the students become tense and she felt like this was not a good start to the semester. Key Issue. This scenario is meant to provide the reader with clarity regarding specifi c faculty and student behaviors that are considered uncivil. Incivility can be defi ned as “speech or action that is disrespectful or rude and ranges from insulting remarks and verbal abuse to explosive, violent behavior” (Clark & Springer, 2007 , p. 93). Academic incivility, on the other hand, “is any speech or action that disrupts the harmony of the teaching-learning environment” (Clark & Springer, 2007 , p. 93). Faculty and students typically do not agree regarding specifi c behaviors considered uncivil. These behaviors should be identifi ed and a discussion should take place regarding ways that faculty can foster civility in the classroom. Principle 7, respect- ing diverse talents and ways of learning, is crucial for this scenario. By making The Flipped Classroom 39 students aware of the respect from the educator, the student learns from role modeling and hopefully continues to respect the educator and other professionals. In addition, the educator needs to respect that all students are adult learners and that they bring unique challenges to the classroom. Faculty Perceptions of Incivility. According to Altmiller (2012 ), faculty have a growing concern regarding student incivility because it “is disruptive to the learning process” (p. 15) and the fact that students who engage in uncivil behavior will be caring for patients. In a study by Clark and Springer ( 2007 ), faculty identifi ed student in-class behaviors that are considered uncivil (in ranking order with most frequently mentioned fi rst): • disrupting others by talking in class • making negative remarks/disrespectful comments toward faculty • leaving early or arriving late • using cell phones (p. 96) Uncivil student behavior outside of class as noted by the faculty (in ranking order with most frequently mentioned fi rst): • verbally discrediting faculty • turning in late assignments without proper notifi cation • sending inappropriate emails to faculty (p. 96) Students’ Perceptions of Incivility By Faculty : • making condescending remarks • using poor teaching style or method • using poor communication skills • acting superior and arrogant (Clark & Springer, 2007 , p. 96) Possible Causes of Incivility in Nursing Education as Identifi ed by Students and Faculty: • high stress environment • lack of professional, respectful environment • lack of faculty credibility and responsiveness • faculty arrogance • sense of entitlement among students • students not really interested in nursing • not being clear about expectations • lack of immediacy to address incivility (Clark & Springer, 2007 , p. 96) Ways Faculty Can Foster Civility in the Classroom . Uncivil behavior by faculty and students can deplete the classroom from optimal learning opportunities. There are several strategies that can be used to promote civil behaviors in the classroom: 1. One of the causes of uncivil behavior, as described by Clark and Springer ( 2007), is the lack of clear expectations. On the fi rst day of class, the faculty should review the course syllabus. A great exercise to follow is to ask the class to make 40 3 Classroom Teaching

a list on the board of expectations of the class that will become the Class Code of Conduct. Examples of statements included on Class Codes of Conduct include: • Be on time for class. • Be present in class. No texting or using technology for reasons other than class activities. • Come prepared for class . • Only get up during a break. • Raise your hand when you have a question. • Be kind to fellow classmates—do not roll your eyes when questions are asked. • Faculty to post assignments at least 1 week prior to class. • This is not an exhaustive list (but it should not be too long). But the key is that the students determine what faculty and student behaviors should be included on the list. I discuss with the class the importance of holding each other accountable when behaviors are noted that do not show adherence to the Class Code of Conduct. 2. I have heard on many occasions how upset students get when they feel that faculty do not address uncivil behavior in the classroom. Hopefully, fellow classmates are addressing the behavior if it violates the Class Code of Conduct . If it is not addressed by classmates, it is crucial that faculty address the behavior. It should be addressed discretely by asking the student (perhaps during a break) to come to your ofﬁ ce after class. Faculty can then discuss the behavior and how it does not comply with the Class Code of Conduct. Students often have difﬁ culty recognizing their own behavior as uncivil. As addressed, the faculty should have a “conversation” about the uncivil behaviors and make sure the student is aware of the expectations and the learning environment.

Scenario Five: Choosing Appropriate Test Items for Course Examinations

Sue has been teaching a medical surgical course with another faculty member for about 6 months. When Sue started teaching the course, the examinations were already prepared and she was only required to submit editorial changes. Now she is being asked to enter exam items on her own. She states that when she went into the computer test bank for the fi rst time, she did not know where to start and how to properly choose questions. Key Issue: The key issue in this scenario is the proper selection of items for a course examination. The focus of this discussion is not about creating examination items (questions) as that is more of an advanced skill and is outside the scope of this The Flipped Classroom 41 book. Rather, the purpose is to assist new faculty with the process of appropriately selecting examination items from the test bank (most test banks are electronic). Where Do I Start? Prior to determining which examination questions to use on the unit or fi nal examination, the faculty should review the test blueprint to determine the number of questions that should be developed for each class section (hour of teaching). According to McDonald (2007 ), there are no “hard and fast rules” (p. 70) when it comes to determining the number of questions allocated per hour of content; however, it is recommended that a systematic process should be followed. For example, if the faculty teaching Diabetes Mellitus takes 75 % of examination, I lecture time versus musculoskeletal (which takes the remaining 25 %), then about three out of four questions should be focused on assessing the learner’s knowledge of Diabetes Mellitus. Selecting the Appropriate Assessment Format . Prior to discussing the appropriate assessment format, it is important to provide preliminary information regarding preparing NCLEX-RN examinations in the nursing program. Student preparation for the NCLEX-RN examination begins early in the nursing curriculum. Selecting appropriate questions to test on the unit and fi nal examinations is challenging, especially if done correctly. Inherent in the process is to understand where the student is. This means that students early in the nursing curriculum should have questions that focus on their knowledge attainment. Using Bloom’s taxonomy, questions should focus on more knowledge and comprehension. The examination questions should ask question such as what is the normal blood pressure for an adult client. As the student progresses in the nursing curriculum, the questions should focus on application and analysis of the nursing content. The examination questions should focus on applying the blood pressure range when a client has a specifi c problem. The best practice is to develop examinations well in advance of the examination date in order to allow all course faculty an opportunity to properly review the examination in totality, thus, assessing the examination to ensure that the examination items are testing at the appropriate level according to Bloom’s taxonomy. Ideally, test questions should be generated immediately following the classroom instruction. Schools should create an experienced group of faculty (faculty who have attended item writing workshops and who have a high level of experience with proper item writing) that reviews examinations to ensure that there is proper alignment and progression of examination items according to Bloom’s taxonomy within each course and throughout the curriculum. This can be accomplished by having a work group established out of the Curriculum Committee that is charged with meeting with all faculty to create and review examinations during the “slower” times in the academic year (at the end of semesters). In most cases, this process does not occur. Faculty are typically so busy during the semester with their various workloads (grading clinical papers, preparing for lecture, preparing for the clinical lab, etc.) that there is not adequate time to properly develop and vet the unit and fi nal examinations. Considering the high-stakes nature of the examinations, it is in the best interest of the student for faculty to allocate time during the semester for examination development. The assessment format is based on the various types of questions that are tested on the NCLEX-RN. These include the standard multiple-choice items and alternate items (an alternate item format is an exam item, or question, that uses a format other than 42 3 Classroom Teaching standard, four-option, multiple-choice items to assess candidate ability) (NCSBN website https://www.ncsbn.org/9010.htm ). Alternate item formats may include: • Multiple-response items that require a candidate to select two or more responses • Fill-in-the-blank items that require a candidate to type in number(s) in a calculation item • Hot spot items that ask a candidate to identify one or more area(s) on a picture or graphic • Chart/exhibit format where candidates will be presented with a problem and will need to read the information in the chart/exhibit to answer the problem • Ordered response items that require a candidate to rank order or move options to provide the correct answer • Audio item format where the candidate is presented an audio clip and uses head- phones to listen and select the option that applies • Graphic options that present the candidate with graphics instead of text for the answer options and they will be required to select the appropriate graphic answer ( https://www.ncsbn.org/9010.htm ) Faculty must “match each outcome with an appropriate assessment strategy” (McDonald, 2007 , p. 67). In other words, selecting whether to assess learning via a standard multiple choice or by developing a question utilizing an ordered response item depends on the objective for the course and unit. For example, knowledge related to a unit objective that speaks to the students’ understanding the steps for donning infection control equipment may best be assessed using the ordered response item rather than a standard multiple-choice item. Faculty should also be prepared to review the examinations after administration. Most schools use some type of test analysis software that generates a Kudor Richardson (KR) score and item analysis. The KR score aids in the reliability of examination and most faculty-generated examinations should have a KR greater than .70 (Tarrant & Ware, 2012 ). Be familiar with what the school has to offer and collaborate with another faculty member to review the test questions. After an examination, removing certain questions or even certain options of the questions may be necessary. This is a common occurrence especially if creating unique test questions. Faculty should also complete a test review with the students. This can be done in a variety of ways. During the examination, the answers can be available for the students to review independently while the other students are still testing. The student should turn in the scantron key or exam booklet and then review the answers. In this type of review, I usually have a rationale at the bottom of each question with reference to the lecture or the book. The problem with this is that the students cannot ask questions about any of the questions because I am still proctoring. I ask the student to mark questions with pencil and then I review them again when I have the item analysis. Another way to review is to put the exam on the projector immediately following an exam. I usually do this for classes that have more than 40 students. Prior to this review, I explain that no cell phones or computers can be available as I do not want my examination nor my test questions compromised. I encourage students to write down any questions The Flipped Classroom 43 using pen and paper. I will go through each question and provide a rationale about the correct answer and why the other answers are incorrect. I also show them clues in the stem in answering the question correctly. In this type of review, I often have students who want to challenge content or questions based on what they recall. The group likes to challenge and it is imperative that you remain calm and refl ective. When confronted and uneasy, I state that I will review all test items using the item analysis, but I really try to listen to where the students are coming from. I try to understand their perspective and listen. The students usually then ask if a question will be dropped or additional credit be given. I usually tell them that I will review the item analysis and then move on to something else. Students need to trust the educator and know that the faculty is preparing them for success on NCLEX-RN. The faculty needs to instill this trust by testing on information that is relevant and necessary. After all, the student will not have the opportunity to ask questions after they take their NCLEX-RN. How Do I Determine What to Test? According to McDonald (2007 ), the “what of assessment is defi ned by the instructional objectives and the course content ” (p. 67) and the “how is directed by the test plan or blueprint” (p. 67). Anecdotally, I hear from students that they felt that they studied everything that was reviewed in lecture by the faculty and read every page of text in the required reading assignment; however, they still fell short and did not pass the examination. Examination questions should be derived from the course objectives and “…important course content. Testing trivia or minor points is a waste of time” (McDonald, 2007 , p. 67). My mantra is that if it is the content that is important enough on which to test the student, then it should be reviewed in class. Prior to administering the examination, faculty should review each question, ensuring that it properly meets the course learning objectives and that it was properly discussed during class.

Scenario Six: Academic Integrity: Cheating on Examinations

Pam was proctoring an Adult Health Nursing unit examination with approximately 45 students. The second faculty member who was supposed to proctor with her was ill and there was no one else available. After the examination started, several students raised their hands to ask questions. She began to notice that as she turned her back to a certain area of the classroom, she would hear the sound of paper shuffl ing and, though she could not confi rm it, she thought she heard mumbling voices. When the examination was over and she inspected the test booklet, several students had written large letters next to the examination item (almost in a way to make what they thought was the correct answer more visible to the other students). Key Issue. The key issue in this scenario is that academic integrity is compromised when students in the classroom are engaging in cheating behavior. Arhin (2009 ) reports that about 70 % of the students at a university of 50,000 students have engaged in cheating behavior; this is up from 26 % in 1963 who were caught cheating. Besides the obvious impact cheating has on the accurate evaluation of student 44 3 Classroom Teaching learning, engaging in such behavior speaks volumes about an individual’s professional integrity. If someone engages in cheating, then it is possible that they may transfer unethical behavior to the clinical setting. This may lead to other potentially harmful mistakes involving patient care. Principle 4, prompt feedback, is essential to the scenario. Cheating on examinations should be dealt with promptly and swiftly. In addition, Principle 6, communicating high expectations, should also be encouraged by the educator. In the scenario presented, the students should be made aware of what the faculty observed. In the classroom setting, the faculty should talk briefl y and sternly about seeing large letters on the test booklet. In addition, the faculty member should also alert the students about the academic integrity policy, which is usually detailed in the student handbook. I usually make reference to the policy in my syllabus at the beginning of the semester. In this case, the information should be reinforced again.

Methods Used by Students to Cheat

Most educators learn about cheating by experiencing it in the classroom or clinical setting. Two reasons that students cheat is a lack of knowledge of the content tested and the rationalization that everyone cheats (Schmidt, 2006 ; Tippitt et al., 2009 ). There are a variety of ways students cheat. The most common type of cheating occurs during classroom examinations. During an examination, students may con- trive ways to retain information using body parts, water bottles, hats, hooded sweat- shirts, and even their phone or watches. Faculty need to be astute to the possibility of cheating during the administration of a classroom examination. Here are just a few simple ways to deter cheating in the classroom. First, make sure that all personal items are in the front or back of the room. Assigned seating or even empty seats between students separates potential collaborators (Stonecypher & Wilson, 2014, p. 169). Test security is the utmost responsibility of the educator. If necessary, make sure the original version of the examination is removed from the copier. In addition, create multiple versions, color code the versions, scramble the option choices on the different version, and most importantly, change the exam questions each semester (Stonecypher & Wilson, 2014 ). Another fundamental mistake is to allow students to view the copy of the test booklet during the test review and then forget to collect the booklet after the test review. Be mindful of this and, if necessary, check the exam booklets against the class roster. Another technique is to allow the student to view the answers to the exam after they have turned in their answer key. On the answer key, rationales and page numbers of answers to the questions can be provided. The students can look at their exam booklet while viewing the answers of the exam. After they have ﬁ nished the review, they turn in their exam booklet. This is beneﬁ cial for both the educator and student as there is immediate feedback on questions. However, this can be disruptive especially if the student wants to give a rationale of why they disagree with the question or answer while the other students are still taking the exam. Often times, I tell the student that we will What Should You Do If You Suspect Cheating During a Classroom Exam? 45 discuss the question after all exams are completed. In classes that have more than 40 students, I always ask for an additional proctor who is either an administrative assistant, graduate student, or fellow faculty to assist. I walk around the room and monitor the students. Usually, the other proctor is opposite of my position in the classroom. I do not bring additional work, unrelated materials, or answer emails during the exam session. For online examinations, students can also cheat. Therefore, technology should be used to assist. Online proctoring is just one example of how to deter students from cheating on an online examination. Attaching a camera to the student’s computer to record the testing session is another way to deter cheating (Stonecypher & Wilson, 2014 , p. 169).

What About Cheating on Assignments?

In the clinical setting, students commonly use plagiarism. Plagiarism, or unethical act of stealing the thoughts of others, is an issue with clinical preparation paperwork. Students can take the information from another student or from an undocumented source such as the Internet. Students need to understand the concept of plagiarism and should be provided with guidelines to avoid plagiarizing, such as proper citation and referencing techniques (Stonecypher & Wilson, 2014 ). By being aware of problems by other educators, faculty can institute policies to deter cheating and plagiarism. The academic integrity policy and its infractions should be clearly stated in the student handbook. This policy should be reviewed and discussed prior to the beginning of each semester.

What Should You Do If You Suspect Cheating During a Classroom Exam?

Policies and procedures must be in place for faculty to follow, to deter, and treat cheating. A recent task force study identifi ed that there are challenges to the implementation of procedures for cheating. These include incomplete adoption by faculty members, faculty turnover, and physical environment limitations (Palmer, Margaret Bultas, Davis, Schmuke, & Fender, 2016 ). The most important message here is to make sure one is able to identify it. If cheating is suspected during a classroom exam, fi rst go and stand close by the student. This is a clear message that you have observed something he or she is doing is wrong. Next, always have another faculty member on call during examination times. For my nursing school, it is either an administrative assistant or coordinator of the program. If I suspect cheating, I will have a student who has completed the exam to ask the assistant or coordinator to come to the room or I have used my phone to text message or sent an email to the 46 3 Classroom Teaching other proctor. If proctoring with another person, alert them of what you are observ- ing and confi rm the behavior. The additional proctor should then continue to proctor the remaining students. After I step out with the student and the exam, I will fi nd another faculty member and go to a private offi ce to discuss the incident. The student should be asked directly what they were doing. One should remain professional and allow for silence during the confrontation. From this point, the process has varied. I have had students deny the allegation of cheating even when I have found the piece of paper with the notes under the exam booklet. I have also had students tell me that they were not using their phone for answers, which was in their uniform pocket, but checking their email. After the confrontation, write up the observation and make sure you have documented what the student told you using direct quotes. In any instance, a clear policy by the academic institution is the guide to follow. One of my course policies in the syllabus states that I follow the academic integrity policy of the school of nursing and I review these course policies at the beginning of each semester. “No matter the prevalence of cheating, the educator’s professional duty remains the same: identify the deviant behavior, to resolve unethical issues, and to develop policies and processes that prevent or correct unacceptable behaviors” (Stonecypher & Wilson, 2014 , p. 168). It is far better to be prepared for this incident rather than waiting for it to occur and handling it inappropriately.

Conclusion

The classroom environment and the teaching that occurs is a crucial element of nursing education. Educators need to be aware of the many components of teaching, which include developing learning objectives of the content, using active learning strategies, and evaluating the material taught. Creating and fostering a learning environment that promotes a union of the educator and student allows each party to become involved and engaged in obtaining the knowledge necessary for providing excellent nursing care.

References

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Giddens JF, Brady DP. Rescuing nursing education from content saturation: The case for a concept- based curriculum. Journal of Nursing Education. 2007;46(2):65–9. Harnish RJ, Bridges K. Effect of syllabus tone: Students’ perceptions of instructor and course. Social Psychology of Education. 2011;14:319–30. doi: 10.1007/s11218-011-9152-4 . Hawks SJ. The ﬂ ipped classroom: Now or never? AANA Journal. 2014;82(4):264–9. Jeffreys MR. Nursing student retention: Understanding the process and making a difference. New York: Springer; 2012. McDonald M. The nurse educator’s guide to assessing learning outcomes. Massachusetts: Jones And Bartlett Publishers; 2007. NLN Fair Test Guidelines. (2010). Fair testing guidelines . Retrieved October 26, 2014. Palmer JL, Margaret Bultas M, Davis RL, Schmuke AD, Fender J. Nursing examinations promotion of integrity and prevention of cheating. Nurse Educator. 2016;41(4):1–5. Perrine RM, Lisle J, Tucker DL. Effects of a syllabus offer of help, student age, and class size on college students’ willingness to seek support from faculty. Journal of Experimental Education. 1995;64:41– 52. doi: 10.1080/00220973.1995.9943794 . Rotenberg R. The art and craft of college teaching: A guide for new professors and graduate students. 2nd ed. Walnut Creek, CA: Left Coast Press; 2010. Schmidt S. Cheating: An ethical concern for nursing educators. Alabama Nurse. 2006;33(1):1–2. Stonecypher K, Wilson P. Academic policies and practices to deter cheating in nursing education. Nursing Education Perspectives. 2014;35(3):167–79. Tarrant M, Ware J. A framework for improving the quality of multiple-choice assessments. Nurse Educator. 2012;37(3):98–104. Tippitt MP, Ard N, Kline JR, Tilghman J, Chamberlain B, Meagher PG. Creating environment that foster academic integrity. Nursing Education Perspectives. 2009;30(4):239–44. Wiedmer T. Generations do differ: Best practices in leading traditionalists, boomers, and generations X, Y, and Z. Delta Kappa Gamma Bulletin. 2015;82(1):51–8. Chapter 4 Clinical Experiences

An Educator’s Perspective

Keeley Harmon

When I started in the faculty role, role as a faculty member, I did not realize just how difﬁ cult taking students into the clinical setting would be. I remember my observations of clinical faculty on the medical/surgical unit when I was a staff nurse. I thought then that being a clinical instructor was an easy job because all they did was babysit students all day. Now, after teaching in the clinical area for a number of years, I realize just how wrong I was! The physical and emotional tiredness and awareness fatigue sets in because as a clinical instructor, I must assign students to patients; review what each student is to do for the day; and then allow those students to proceed with their patient care. Then, my panic sets in—how can I be with each of these students when needed? how can I be sure these patients are safe? It is impossible to be aware of what my students are doing at all times. There is also the fatigue that occurs because of the challenges of feeling spread too thin; trying to determine the fate of a student based on their clinical performance; trying to develop thought provoking learning activities and relevant patient assignments, and trying to develop meaningful post-conferences (just to name a few). These are all essential to helping students apply that they have learned thus far in the program together yet they place great demands on the nurse educator. In spite of these challenges, there is joy in witnessing the light bulbs turn on in students’ heads that keeps me going back for more along with the knowledge that clinical experiences are where students begin to synthesize everything that is being taught in the classroom setting. This is where it really happens! The reality of clinical (or practicum) teaching is that there are more students being assigned to each faculty member, with nine or even ten students rapidly becoming the norm. Additionally, in order to ensure adequate faculty coverage for clinical, many schools are forced to ﬁ ll vacancies by hiring extra adjuncts or offering additional workload for full time faculty. New faculty teaching in clinical are

© Springer International Publishing Switzerland 2016 49 K.C. Harmon et al., Nurse Educator’s Guide to Best Teaching Practice, DOI 10.1007/978-3-319-42539-9_4 50 4 Clinical Experiences typically skilled and experienced practitioners, but most have no prior experience in the complicated, unpredictable world of teaching nursing in the clinical environment. Most come to the teaching setting with their only education experience being their own. Thus, this can lead to a “teach as I was taught” mentality depriving the recipients of clinical teaching consistent with current best education practice and leading to what Brookfi eld ( 2006 ) calls “uninformed teaching” (p. 24). Conversations with several new clinical faculty revealed that prior to the beginning of the semester they received a short orientation to the school mission and purpose along with the overarching do’s and don’ts for faculty but they received no true, sustained clinical orientation and guidance. Many were unfamiliar with the school’s curriculum and did not receive the course syllabus containing the course objectives and course content. Remarkably, many were not informed about the weekly clinical paperwork requirements and thus created their own assignments which were different than that required by the other faculty in the same course. Other conversations with nurse educators were equally as revealing as several novice nurse educators recalled their fi rst days on the unit with students. One stated that she let her students follow the nurses on the unit for the fi rst couple of weeks because she did not feel comfortable assigning patients to them. Others recalled being faced with a variety of diffi cult issues such as students showing up unprepared to provide safe patient care; students showing up late; and students communicating unprofessionally. These novice nurse educators recalled feeling unprepared to make decisions for the various situations they faced. Questions may arise in the novice educator’s mind such as: who do I call? Or what is the appropriate decision based on the seriousness of the situation? Both novice and experienced nurse educators encounter scenarios during their clinical or practicum oversight that require careful consideration. The purpose of the following section is to present a guide for both the novice and experienced nurse educator regarding some of the most common scenarios encountered in the clinical setting. It is important to emphasize that nursing faculty for the most part want to create the best possible learning environment for the students; however, even the best intended faculty can utilize approaches that simply do not work. This does not signal failure on the part of the faculty. In fact, it is quite the opposite. As Brookfi eld (2006 ) stated, “risk is endemic to skillful teaching. Good teachers take risks in the full knowledge that these will not always work” (p. 268).

Scenario One: Being a Clinical Instructor for the First Time—What Do I Do?

Pam is new to teaching nursing students in the clinical area. She transitioned to nursing education following 10 years working as a nurse practitioner in a family practice setting. Promptly after starting in August she attended a 3-day faculty orientation session Which focused on a review of institutional information) and then she received her assignment. Part of her assignment was to teach in the clinical portion of the Fundamentals of Nursing course. She met with the faculty and reviewed the clinical information, including the syllabus and required student An Educator’s Perspective 51 paperwork, and then she shadowed a nurse on the unit for about three shifts. During the fi rst week of clinical she met with her students. She felt clumsy discussing the expectations, paperwork, etc. but she managed to get through it. When they got up to the clinical unit following orientation, she realized that she needed to make a clinical assignment for the fi rst week. However, she really felt out of sorts because she had never made an assignment before. She did not know where to start. Key Issue : Pam did a lot of preparation prior to the start of the clinical rotation. She attended the college orientation session; met with the course faculty; and shadowed a nurse on the clinical unit. All of these are crucial to facilitate the smooth transition into the clinical area and are part of many institutions new faculty orientation programs. For most new instructors, however, further information is necessary, including: • Basic preparation of new clinical faculty • Making clinical assignments • Organization of the clinical day • Critical thinking activities to challenge students in clinical • Engaging students in post-conference Basic Preparation of New Clinical Faculty. Clinical faculty need to have the proper tools in their tool kit prior to starting the clinical rotation, especially for the fi rst time. The following are examples of best practices for effective clinical preparation: • Clinical Organizational Tool . Faculty need some type of tool to document important patient and student information ( Appendix D). This tool provides a means to keep up with all students’ patient assignments, pertinent patient information, and discussion topics to cover with the students. • Review Students’ Transcripts. One mechanism to have a general picture of your assigned students’ academic performance is to review their previous coursework. This will only provide one snapshot of the student but it can give the clinical faculty a general sense of potential areas of growth opportunities. For example, if you notice that a student made a failing grade in Pathophysiology and repeated the course and made a “C” the second time, you may have identifi ed an area of opportunity for that student. One thing I do not recommend, however, is for faculty to engage in discussions about student performance. In other words, clinical faculty who have previously worked with a student should not discuss the students with faculty in upcoming courses. In every case that this has occurred (and it does occur), faculty have been infl uenced by the information discussed making it extremely diffi cult to subjectively assess student performance. I cannot tell you how many times faculty have attempted to discuss student performance with me and I have had to stop them in mid sentence and state, “I appreciate your wanting to discuss this with me; however, I prefer to assess students based on a clean slate.” I must add here that some schools do not allow review of student records in this manner—please refer to your institution’s policies and procedures. • Student Contact List. This may sound trivial, but having been through a hurricane where there is no access to technology other than texting on cell phones, I learned the hard way that it is absolutely crucial to acquire student personal contact information on the orientation day. Table 4.1 is an example of the tool that you can utilize. 52 4 Clinical Experiences

Table 4.1 Sample contact information page (Insert faculty name here) Clinical group contact information Student/faculty name Cell phone number

Making Clinical Assignments. Making effective and appropriate clinical assignments is a key skill for the clinical instructor and is integral to student learning. It must be a thoughtful process that takes into account the course objectives, content outline, and student goals. At the same time, it necessarily takes place within the limits of the unit and the census. The fi rst week of a clinical rotation should involve meeting with the students during orientation to discuss the course, clinical expectations ( Appendix A), and required paperwork. Recognizing that students’ anxiety is through the roof, it is useful to open with an icebreaker, such as asking them to introduce themselves and tell the group one thing no one knows about them. During this fi rst it may be helpful to avoid assigning the students to a patient of their own. Instead, pair up the students up and allow them the opportunity to acclimate to the fl ow of the unit and get used to the staff. No medications are distributed this fi rst week either. Rather, the focus is to work in a partnership, becoming familiar with the unit and the routine. The pairs may also work together on the clinical paperwork. An effective strategy to engage Principle 2 of good practice in undergraduate education (develop reciprocity and cooperation among students) is to use Google Docs together as they can actually see the work that is being done in real time. This is an excellent way for the faculty to see exactly how the pair divided up the work for completion of the paperwork, since faculty can see all edits on the document. Each week students turn in a personal refl ection responding to the following: • Describe a situation … – that required you to use critical thinking skills. – where you communicated effectively. • Overall … – What were your strengths this week? – Describe areas of opportunity. – For next week … – Use your course content outline and determine a disease process that you would like to learn about. – What skill would you like to try to perform? – What other goal do you have with regard to clinical? An Educator’s Perspective 53

Once the fi rst week is complete, and the students have had the opportunity to work in pairs to get accustomed to the clinical environment, the second week will be an opportunity for students to work individually. It is important that you review the student’s refl ections and bring these with you as you go to preclinical. Preclinical is the day prior to the clinical week where students come to the fl oor to acquire their assignments. Faculty should allow about 1 h prior to the scheduled preclinical time to make the assignments. Meet with the charge nurse and determine which patients may be discharged in the next 24 h; and which patients may not be suitable for students (prisoners, patients with multiple complaints, etc.). The caveat with the former statement is that there are schools with exceptions not allowing the preclinical day—it is ideal, however, that it may not occur in all cases. Use the refl ections to make the clinical assignments (this engages Principle 7 of the good practice principles in nursing education as it respects diverse ways of learning and takes individual learning needs into account). Think back to the previous week and assess the type of experience students were exposed to. Keep the course objectives and course content outline in mind while making the assignment. Sometimes you will assign patients to the students who are discharged before the next clinical day. Students come to clinical and note that their patients are no longer in the hospital. Students will be discouraged because they will have completed all the clinical paperwork on this patient. It is important to let the student know that their hard work will be reviewed. You can assign the student another patient and have them complete abbreviated paperwork ( Appendix K ). Another very important element of the clinical week is for the clinical faculty to meet with each student individually during the preclinical time. This provides an opportunity to review the paperwork from the previous week, discuss goals and identify areas of improvement. Organization of the Clinical Day . For a new clinical faculty, it can be quite intimidating trying to ensure that up to ten clinical students get the best learning opportunity possible. The best way to negotiate optimal learning opportunities is to strategically organize each clinical day. This may look something like this: • 0630: students arrive to fl oor. • 0640: acquire the list of patients and determine if any of the student’s patients were discharged. Have the students identify which nurse is assigned to their patients and then go listen to the morning report. • 0700: take the Clinical Organization Tool and fi ll in key information: baseline/ latest vital signs on each patient; labs; medications that the students will be responsible for and the times they are to be administered. • 0800: begin to pull 0900 medications and go with each student to administer them. This usually takes approximately 2 h, depending on the setting and the number of patients and students. At the same time, this provides an opportunity to quiz each student about aspects of their patients’ status and care. • Critical Thinking Activities to Challenge Students in Clinical. There are many activities that can be used to stimulate student critical thinking and incorporate principles of good practice in undergraduate education (specifi cally, Principle 3). 54 4 Clinical Experiences

One of my most successful tools is what I call “Quick Response.” Since I put them on laminated index cards they are called “Quick Response Cards (ORCs).” During clinical orientation I tell students about these cards and that at any time during the day they may receive a card. The cards contain a situation that could in real life occur to any nurse. The student must pretend that the situation on the card is actually occurring in clinical. They have to stop and process through (write down) exactly what they would do given that situation. These situations provide for excellent dialogue in post-conference. Examples of the scenarios are listed below. You have permission to use these situations and let them guide in the development of additional scenarios.

You walk into your patient’s room and he is on the ﬂ oor following an apparent fall. What is your priority? What should you do? Your pager just went off and you have been told by the monitor technician that your patient had an 8 beat run of ventricular tachycardia. What is your priority action?

Your patient is due for surgery (ORIF left hip) this morning and you have an order that the patient is NPO except medications. The patient is due to get captopril, aspirin, enoxaparin, and famotidine. Do any of these medications concern you? What do you do? Your patient just called out and stated that he is having chest pain. What do you do? What is your priority action? Discuss the tentative sequence of events.

Engaging Students in Post-Conference . Post-conference is an excellent time to debrief on the clinical day. Benner, Sutphen, Leonard, and Day (2010 ) discuss the need for this designated time stating that it allows for the “intentional integration of knowledge, clinical reasoning, skilled know-how, and ethical comportment” (p. 159). It is important that the clinical faculty develop learning objectives to guide each post-conference. Initially, I like to go around to each student and they are asked to state at least one thing they learned during the day. Afterwards, the QR cards are discussed. Students state that they really enjoy these because they require critical thinking. Those are the two activities that are completed at each post-conference. Other activities are planned based on the course learning objectives and content outline. For example, if basic electrocardiogram interpretation is part of the course content, I bring in multiple 6-s strips for students to apply what they learned. These methodologies ensure that principles of good practice in undergraduate education are followed (Principles 1, 2, 3, and 7).

Scenario Two: Supporting a Student Who Is Performing a Skill for the First Time in Clinical

Pam is a new faculty who is in her second week of clinical with her Fundamental level students. Prior to starting this clinical rotation, she shadowed another faculty for a few weeks. She observed a student perform a skill (Foley catheter insertion) for An Educator’s Perspective 55 the fi rst time. The faculty expected the student to gather the supplies, review the skill, and perform the skill without any guidance from the faculty. The faculty cri- tiqued the student heavily in front of the patient and she observed the student’s hand shaking (from obvious nervousness) during the insertion of the catheter. After the completion of the skill, the faculty did not provide the student with any positive reinforcement or helpful, constructive remarks regarding needed areas of improvement. Rather, she only had negative words and she mentioned that the student needed to go back to the skills lab for remediation. Key Issue: The key issue in this scenario is how to best support a clinical student who is performing a new skill. Providing the Support. Performing a skill for the fi rst time in the clinical setting can be a very nerve wracking experience for nursing students. They are asked to translate skills and competencies from a predictable, static skills lab environment to the unpredictable hospital setting. For example, in the skills lab it is quite easy to put a Foley catheter in the manikin, whereas Foley insertion in the hospital environment can be much more challenging if the patient is obese or uncooperative. Compounding this complexity is a family expressing concern that a student is performing the procedure. Faculty behaviors can also lead to students’ increased nervousness when it comes to performing new skills in the clinical setting. Students who perceive that the clinical faculty are not engaged in student learning in a nurturing fashion will tend to be more reluctant to perform new skills and may exhibit more nervousness while performing the skill (aligns with Principle 2). This is certainly not implying that students should be absolved from their responsibility in coming to clinical prepared and seeking out appropriate resources when it comes to performing new skills. What is key here is that student learning is optimized when faculty engage in a caring approach relative to guiding a student through the performance of their skills in the clinical setting. Students should sense that faculty are interested in their learning. When the opportunity to perform a new skill arises, the faculty should meet briefl y with the student. During this time, the faculty should discuss with the student the work/ inquiry to be done prior to going into the patient’s room to perform the skill. The following is what I ask the student to do: 1. Go into the patient’s chart and review the order and be prepared to show me (the faculty) the order. 2. Review the steps in the skill (either in a skills book or in the video series approved by the hospital). In addition, the student should review the hospital policy and procedure for the particular skill. 3. Acquire the necessary supplies. All of these steps usually take about 20 min (this assumes that the order is not needed immediately). Prior to going into the patient’s room, the student should show the faculty the order in the computer. Next, the student should review the steps in performing the skill outside of the patient’s room. Once the skill is performed, it is vital to come outside the room and debrief. I usually ask the student their perceptions regarding what went well and what were the areas of opportunity. Doing so in a caring fashion is an ideal approach to reduce the student’s anxiety and promote learning. 56 4 Clinical Experiences

Scenario Three: Unprepared Student

Jane is an advanced practice registered nurse with about 10 years of experience in the clinic setting. She accepted an offer to work as a practicum adjunct faculty in the baccalaureate program’s fi rst medical-surgical course because she wanted to participate in the education of future registered nurses (and the salary was an incentive as her son just started college). The fi rst couple of weeks of practicum went relatively well as Jane made a decision that the students would obtain a patient assignment in dyads and complete the paperwork together. The third week, mid semester, was a different story altogether. Students were now required to individually complete their paperwork and were being asked more specifi c questions about their assigned patients. Jane was particularly concerned about one student as she was not able to answer any of the questions regarding her assigned patient and her paperwork was incomplete. Jane made a global statement to all students regarding her expectations of their practicum preparation and paperwork completion for the last 3 weeks of clinical hoping that it would resonate with this particular student. During the 4th week of practicum, Jane assigned this particular student a rather challenging patient who required medication administration via a PEG (percutane- ous endoscopic gastrostomy) tube hoping that she would rise to the challenge. Jane completed medication administration with all other students and purposefully waited until the end to work with this student. Jane asked the student four questions regarding the rationale and the method of action of two of the medications. The student began to shake and she told Jane that she simply did not know the answer. Jane asked the student to retrieve her clinical paperwork and upon review, the paperwork was clearly incomplete (the student did not document any of the nursing diagnoses). Key Issue : When a student has been identifi ed as being unprepared in the clinical setting, it can be challenging to determine the appropriate intervention. In many cases, faculty may opt to send the student home and give a failing grade for the day. Prior to determining potential appropriate interventions, it is important that faculty understand how to clearly defi ne the clinical expectations. Setting the Clinical Expectations . Principle 6 of the Principles of Good Practice in Undergraduate Education identifi es the need to communicate high expectations. Students are more likely to complete the required paperwork and receive an adequate learning experience after properly receiving expectations by the clinical faculty. Faculty should review the expectations with the students in a face-to-face fashion in order to provide the students an opportunity to ask questions. The following are strategies for outline expectations: • Provide the clinical students clear performance expectations prior to the beginning of the clinical rotation. This can very easily be accomplished with a clinical syllabus (example provided in Appendix H). Included in this clinical syllabus are the faculty expectations related to preparedness and the potential repercussions if the expectations are not met. A clinical orientation session should be scheduled in order to outline for the student exactly what is expected and what strategies the An Educator’s Perspective 57

faculty recommend to best prepare for clinical. Additionally, faculty should outline specifi c institutional and school policies applicable to the clinical setting. • Faculty must from time to time review their paperwork expectations and determine if the requirements are realistic given the other curricular demands on the student. Typical requirements include a fully developed clinical care plan; medication cards on all medications that the patient will be receiving; pathophysiology cards on the admitting diagnosis as well as all comorbid factors. It must also be realized that students are often enrolled in two or three concurrent nursing courses so this paperwork is not all that must be completed in a given week. The student may also have theory examinations that require adequate focus and attention. According to Gaberson, Shellenbarger, and Oermann (2015 ), faculty should avoid writing assignments that merely require extracting information from a textbook or resource. Rather, assignments geared toward higher level thinking skills can be relatively short and aimed at achieving the course learning outcomes. An example of this type of assignment is: Briefl y describe two medications that you will be administering to the patient that are directly related to the admit diagnosis and identify the priority assessments that you will be performing. Questions that Faculty Should Ask When Encountering the Unprepared Student : • What are some possible reasons why this student did not get the work done? Are there personal issues restricting the student’s ability to complete the preparation? Is it possible that the student does not feel comfortable discussing their plight with the faculty? It is crucial that faculty exhibit caring behaviors to the students. As noted by Dillon and Stines ( 1996), faculty who “listen attentively and non- judgmentally [will] allow the student to speak freely and think creatively” (p. 115). • Has this been a consistent problem? • What consequences will benefi t the student’s learning the most? • What is the level and skill preparation of this student? • What are the course and department policies? • What are my resources? Should I involve someone else in helping me with this decision? Should I contact the course coordinator to discuss? • Have I done everything that I need to do as the facilitator of learning for this student? Have I been clear with my expectations from the beginning? This list is not exhaustive but it represents most of the questions that clinical faculty should be asking prior to making a decision regarding the consequences for a student such as the one described in the scenario. In many nursing programs, the course coordinator organizes at least one meeting with all clinical faculty in order to discuss the syllabus, required clinical paperwork, and the process to follow in instances where disciplining a student may be necessary. In order to ensure that course decisions are consistent and equitable, the course coordinator usually requests that clinical faculty contact the course coordinator as soon as a situation occurs. A conference call may be scheduled to enable a 58 4 Clinical Experiences conversation amongst all clinical faculty regarding the situation; the goal with this approach is to ensure that all clinical faculty are making consistent clinical decisions. While it is important to make sure that consistent decisions are made, the literature is clear that educators “have struggled for some time over the issues and inconsistencies of assessing and evaluating students’ clinical behaviors” (Tanicala, Scheffer, & Roberts, 2011 , p. 155).

Managing Clinical Unpreparedness When It Occurs

• If this is not a consistent problem, the faculty should meet face to face with the student in a caring, non-threatening manner and discuss the reasons that the preparatory work was not done. This is an excellent opportunity to discuss the potential negative impact that could result from lack of preparedness (for example near misses, etc.). Some faculty contend that a student should be sent home on the fi rst and subsequent occurrences of unpreparedness. This is not usually the best solution; especially if one thinks about the consider- able learning that is lost by sending the student home. The faculty must determine if the student is capable of turning the situation around after rees- tablishing the guidelines. If this behavior recurs, the faculty must follow the established course guidelines; this will probably necessitate a conversation between the course coordinator and other clinical faculty. It is paramount that a degree of consistency is maintained. When it is discovered that the clinical student has multiple infractions related to unpreparedness, it is acceptable to inform the student that their repeated unpreparedness is unacceptable; however, the faculty member must discuss the issue with the other course faculty to determine the repercussions. One such approach that can be instituted is the use of a clinical contract developed by the student. The use of a clinical contract can enhance autonomy and increase the motivation for learning (Chan & Wai-Tong, 2000 ; McAllister, 1996 ; Rogers, 1983 ). Appendix J illustrates an example of a clinical contract that can be utilized. Allowing the student to complete the clinical contract provides an opportunity for critical self-refl ection to occur. Wan Yim et al. ( 2012 ) state that refl ection is an active, dynamic process that aims to provide “new or revised interpretation of the meaning of an experience, which guides subsequent understanding, appreciation, and action” (p. 254). The hope is that the student will gain a renewed understanding of the impact of their behavior. • Have the student stay in clinical and provide an alternate assignment such as spending time getting information she/he missed? Perhaps perform assessments on three or four patients? This may be benefi cial if conducted in such a way as to also provide the student the opportunity to refl ect on their unpreparedness. Managing Clinical Unpreparedness When It Occurs 59

Scenario Four: Not Enough Time—Spending Appropriate Time with Each Student

Carol has worked as clinical faculty for approximately 1 year. The following is an excerpt from her refl ection following a semester rotation with sophomore level students: “I am terribly frustrated after this semester. I found it extremely diffi cult to devote adequate time to each of the ten students in my clinical group. I felt like I was spending most of my time running from one student to the next and was unable to take the proper time to talk to each student about their patient and assist them in integrating their assigned patient’s information with the course content. Nor was I able to work with them on developing their critical thinking skills. I even had three students that I considered weak and I don’t feel like I was able to fairly assess whether they were too weak to progress to the next level. I am sure I will hear about it from the faculty in the senior level courses; they will want to know who those students had in clinical and why in the world the faculty did not fail them. Well I know why! I could not properly assess them given that I had ten students who all needed me ALL THE TIME. I did not stop for a second to catch my breath. Am I alone? I don’t ever hear other faculty talking about how they feel the way I do. They complain about having ten students but I never really ever hear them talk about being concerned about being an effective teacher or strategies to be an effective teacher given all we are responsible for.” Key Issue: The primary issue in this scenario is the faculty’s concern regarding the high faculty to student ratio and the perceived inability to properly manage the group and provide an adequate learning experience. Another issue is the management of a student or students in clinical that are perceived to be weak, especially in a situation where there is a high number of students. This presents a challenge to the Principles of Good Practice in Undergraduate Education because Principle 1 relates to encouraging contact between students and nursing faculty. This becomes challenging when the ratio of students to faculty increases. Additionally, it becomes challenging to provide prompt feedback (Principle 4) in these situations. Management of a Large Clinical Group. For a variety of reasons, schools of nursing are fi nding it diffi cult to fi ll all of the clinical adjunct positions. Thus, clinical faculty are, in many cases, being required to supervise the maximum number of students allowed by the State Board of Nursing. More students mean that clinical faculty have to be able to assess student progress and ensure their safety in providing care to patients all while maximizing learning opportunities. One way to facilitate all student learning is to rotate one or two students for observation only opportunities in other areas of the hospital (if supported by the hospital administrators). These opportunities must be strategically planned and they must be part of the course learning objectives. For example, in the medical/surgical clinical course, students were learning about cardiac diagnostic procedures. Therefore, two students rotated off of the unit in each day to learn about different cardiac procedures. They were able to report back to the group during post-conference regarding their opportunity and what they learned. Identifying and Managing “Weak” Students . This can be one of the most diffi cult aspects of clinical teaching. Many students who may be determined to be “weak” could meet outcomes with proper mentoring. These students often reveal themselves when 60 4 Clinical Experiences meeting to review paperwork and refl ections. Once it is discovered that a student may not be meeting outcomes, goals should be established early and specifi c follow-up should be ensured. An action plan can be developed if certain behaviors occurred that revealed unsafe clinical behavior. See Appendix K for a sample action plan.

Scenario Five: Today’s Student

The following is an excerpt of dialogue that occurred between faculty during a meeting. This dialogue is focused on the characteristics of today’s clinical student. “Faculty 1: You know I just cannot believe my students. For the most part they seem lazy and unmotivated. Most of my clinical students act like it is an inconve- nience to take care of their patients. Faculty 2: I could not agree more. I was shocked when I told my med/surg students to give their patients a bed bath and they looked at me like I had three heads. They actually told me that they thought that was the role of the nursing assistant and asked me why they had to do that. I would never had said that to my nursing faculty when I was in school. What is with these students? Faculty 3: Oh I know all too well. I actually had to pull a student out of a room when she answered her personal cell phone in the patient’s room. And I even discussed that with them and it is listed in my clinical syllabus. Faculty 1: That’s amazing. What’s happening? Is it just our school or is this an endemic problem? I could not believe it myself when I told the students to pick their own patients and you know I was surprised that they chose patients that were very easy rather than patients that might challenge their thinking. Is there something we should be doing to help motivate these students?” Key Issue: The key issue in this scenario involves an understanding of the characteristics of today’s student. What’s the Difference? It is important that faculty develop an understanding regarding the primary differences in today’s students. A better understanding will necessitate changes to teaching methodologies that aim to enhance student learning. The majority of today’s students are known as the Y Generation (also known commonly as nexters and millennials). They are individuals born between 1980 and 2000 and according to Hutchinson, Brown, and Longworth ( 2012) are the largest generation to enter our workforce since the baby boomers. Montenery et al. (2013 ) characterize Generation Y students as “confi dent, team-oriented, high-achieving, pressured, traditional, and sheltered” (p. 405). Their learning and critical thinking development is enhanced through the use of teamwork, technology and experiential learning. These students are multi-taskers and are accustomed to “immediate, auto- matic feedback, and desire positive reinforcement” (Montenery et al., 2013 , p. 405). Hills and Boshoff (2015 ) interviewed faculty and developed themes regarding perceptions of Generation Y students. Participants described these students as “self- assured go getters that are team players but are easily bored; demanding, motivated learners; and technologically savvy” (Hills & Boshoff, 2015 , p. 6). Generation X students, by contrast, were born between 1965 and 1979. They are described as being independent as many were raised in an environment with either Managing Clinical Unpreparedness When It Occurs 61 both parents working or as a product of divorce. As a group, they tend to disavow corporate life and tend to challenge authority. According to Walker et al. (2006 ), these students prefer that faculty focus on the outcomes of learning and not necessarily the process. They want assignments and faculty expectations to be clearly outlined and refl ect the real-world skills they will need to succeed. So What Do We Do With This Information? Clearly, Generation X and Y students have certain characteristics that can infl uence their learning. But the real question here is what can nursing faculty do to stimulate this group and optimize the learning experience? This may not be as diffi cult as it sounds. It comes down to promises. It is about making a pledge to these students during the orientation process—prior to starting clinical. Specifi cally, as we previously stated, informing them of the specifi c expectations through the use of a clinical syllabus. But it is important to go a step further. Develop a quick (maybe a one page document) outlining your commit- ments to the students and also outline what a “good student” looks like. This provides a layer of transparency that these students crave. In your one page of promises you may want to include things such as: I PROMISE TO … • provide you with feedback on your clinical paperwork • praise you for the things you do well • inform you in private when areas of opportunity are observed • understand that you get bored easily and will provide meaningful activities to stimulate your real-life thinking • inform you of the learning goals • be enthusiastic and motivating • be nurturing • maintain high standards for clinical • be a positive role model • help you develop a community of learners • understand your individual learning characteristics On the same page, describe characteristics of an outstanding student , a person who: • comes prepared for clinical • communicates with all in a professional manner • always keeps the needs of the patient and family fi rst • expresses an enthusiastic attitude toward learning • is self-directed and seeks learning opportunities (with faculty approval) • touches the patient therapeutically before touching the equipment • CARES • leaves attitude at the door • asks others what you can do to help (not just nurses but all staff) • stays fl exible For the most part, students want to please their instructor. Students crave positive reinforcement and at the same time, they want to know quickly if they have not met the learning objectives. Students also seek an understanding of real life nursing and 62 4 Clinical Experiences no one can provide that to them better than faculty. Faculty should provide specifi c practice examples of things that happened to them in practice and how they resolved practice issues. Here is an example: I told my students about a situation that I was involved in as a new nurse. The patient and his entire family came to the hospital after the patient’s beeper went off, notifying him that he would soon be a recipient of a heart transplant. We were notifi ed on the fl oor of his pending arrival and we began to prepare. This was back in the day prior to computer entry and we had to post order requisitions by hand and notify each department regarding the patient’s pending arrival. The patient did in fact arrive and he and his family were brought to their room by the unit secretary. I was not far behind; however, I was trying to put the fi nishing touches on the orders as timing was critical. I had about 1 h from arrival to fully prepare this patient and I was trying to make every moment count. The patient was on the fl oor approximately 15 min when I received a call from nursing services that the patient was calling to complain that he had not seen a nurse yet. Initially, I recalled being very angry that the patient would call nursing administration; however, given the circumstances I put those emotions aside. When I went into the room I remember feeling the anger, fear, frustration, you name it. I took a deep breath and said, “I know you must be very scared. My name is Keeley and I will be the nurse preparing you for surgery. I am going to tell you everything that will be happening in the next hour. Please know it will be very busy and a lot of people will be coming in your room. But I will tell you exactly what to expect.” Immediately I sensed the frustration and anger leave the room. Acknowledging the emotion in the room was a huge defl ator for the patient and the family. I use this scenario with students to discuss the impact that therapeutic communication can have on a patient encounter. Immediately students can relate to this scenario and, in fact, I have had students come up to me months or years after informing me that they used a similar strategy with great success. Another strategy for engagement is the use of “what ifs.” This can be used at any point in clinical learning. For example, when getting ready for medication administration, ask “What if the patient shows symptoms such as X, Y, and Z after you give this medication?” “What if your patient has a heart rate of 40 before you give the lanoxin?” This becomes a part of their daily routine. Do not be surprised if you hear students asking each other the “what if” questions! All of these strategies tend to appeal to Generation X and Generation Y learners as these students tend to desire the real world, practice knowledge, and want to be stimulated. How Should I Handle a Student That I Suspect Is Impaired? In order to protect the public, most state boards of nursing require a criminal background check and subsequent drug screening of all prospective students entering health care agencies for clinical. Unfortunately, according to Murphy-Parker ( 2013 ), approximately 10–20 % of student nurses experience substance abuse and this may not be revealed prior to entering the nursing program. Therefore, it is crucial that nurse educators be aware of: (1) ways to prevent abuse and assist students; (2) signs and symptoms of impairment; (3) how to handle impairment when it is suspected. Managing Clinical Unpreparedness When It Occurs 63

Ways to Prevent Abuse and Assist Students. The 1993 National Student Nurses Association House of Delegates passed a resolution requesting that all schools of nursing develop mandatory education regarding health care provider impairment and develop policies regarding how substance abuse by students will be handled. Informing students up front about the potential for program dismissal for impairment can serve as a strong deterrent for this behavior. This can be an essential component of the clinical syllabus. Speciﬁ cally, outlining the consequences of suspected or conﬁ rmed impairment. Signs and Symptoms of Impairment. Baldisseri (2007 ) outlines the following signs and symptoms of impairment : • absenteeism or arriving late to the clinical setting • taking frequent breaks and needing to leave early • poor preparation for assignments • judgment errors inappropriate to the level of education • illegible or illogical charting • inability to recall details about assignments • discrepancies between student and staff assessments • wide variations in performance each day • drowsiness or slowed actions • sloppy appearance • tremulous hands • odor of alcohol on the breath • slurred speech • nodding off during conversation How to Handle Suspected Impairment . If you suspect impairment in one of your students, it is imperative that you remove them from the immediate clinical area (but still in an area such as faculty lounge—assuming they are cooperative and not disruptive). You must call the school and notify the individual who is in charge of clinical (Program Clinical Coordinator) as well as the course coordinator. Next step will be in accordance with the school’s policy. In most cases this will involve the student being escorted to a facility for a drug test. You as the clinical faculty must document the exact suspicious behavior/symptoms necessitating this action.

Scenario Six: Proper Feedback on Summative Clinical Evaluative Tools

Kim, a clinical faculty member with about 15 years clinical teaching experience, was speaking to one of her clinical students upon the completion of the clinical rotation. The student disclosed to Kim that she appreciated the thorough and constructive feedback provided to her on the weekly evaluations as well as on the end of rotation clinical evaluation tool. The student stated that this was the fi rst time that she got such thorough feedback in clinical; she was used to receiving evaluations that were incomplete and without any type of feedback. In fact, she said that she 64 4 Clinical Experiences typically never received much feedback on any of her clinical paperwork either. Kim began to refl ect on the conversation with the student. Is this true? Are faculty providing adequate and timely feedback to the students? What type of feedback is appropriate to enhance the development of the professional nurse? Key Issue: The key issue in this scenario is recognizing the importance of specifi c, timely feedback regarding clinical performance (Principle 4—Principles of Good Practice in Undergraduate Education). A secondary but similarly important issue is the importance of feedback on clinical paperwork. Feedback Regarding Clinical Performance . The reality of being a clinical faculty member is that the pace is demanding and it is diffi cult to fi nd time to document anec- dotal notes regarding individual student performance. A useful strategy is to jot down small phrases on the Clinical Organization Tool ( Appendix G) and return to it later. For example, if a student was late for a particular shift, jot down “Late 7:10.” This removes the need to remember which student was late that morning what time the student arrived. The importance of prompt feedback has been noted, and the issue of tardiness provides an example where this can be applied. In my own practice, I require any student who knows that he or she will be late to send me a text message and also to call the fl oor (developing professional comportment). I will usually message them back stating “okay this is #1. But please tell me why you are late so that I can help you.” This communicates two clear messages: that lateness must not become a habit, and that I care about them. During clinical orientation I explicitly review the policy regarding lateness and acknowledge that unexpected things occur, but emphasize that professionalism is an integral part of nursing practice. During our weekly scheduled meeting the student goals and refl ections are reviewed. If the tardiness is not refl ected upon by the student, then I ask that refl ection take place, especially if a pattern is identifi ed. If the behavior does not change, and despite multiple meetings and discussions regarding a need for a change in behavior, an escalation of the issue is required. Throughout this process, maintaining timely and detailed documentation is imperative. Faculty must thoroughly document student actions in relation to course learning objectives. Prior to providing the student with a formal written corrective action plan, it is necessary to have a conversation with the course coordinator and other course clinical faculty. All faculty must be on the same page when such decisions are made in order to maintain consistency of both expectations and consequences. Feedback on Clinical Paperwork. Grading clinical paperwork can present a daunting workload. With 8–10 students in clinical, the number of care plans, drug cards and pathophysiology write ups that require feedback can accumulate quickly. Providing feedback that is thoughtful and specifi c requires large amounts of time and energy. However, students are disheartened and frustrated when they speak of receiving their paperwork back with only a big check mark on the front page. It is clear that the clinical faculty did not review the work in any detail. This frustrates students because they genuinely desire feedback on the paperwork that takes hours to complete. Feedback is pivotal to learning and students typically require multiple encounters with information before it “sinks in.” One-on-one meetings are an ideal time to review clinical paperwork and to explore the thought processes that the student applied when completing it. What About Faculty That Tip the Scale and Want to Be Everyone’s Best Friend? 65

Scenario Seven: The Great Intimidator

Karen is the course coordinator of a medical/surgical clinical practicum course. She met with a student who was upset regarding the way she was treated by her clinical educator. During the meeting with Karen, the student mentioned that the clinical educator made comments such as, “I cannot believe you did not know that” and “I am not here to give you answers to everything—look up your questions on your own.” The student stated that she was afraid to go to clinical because the educator berated everyone and she did not feel like she was learning anything. The student asked Karen “Why is it that you all talk so much about teaching us the ‘art of caring’ but yet some of the faculty treat students so horribly?” Key Issue: In keeping with Principle 1 of the Seven Principles in Undergraduate Education, faculty are responsible for facilitating a positive learning experience. Most faculty provide this type of experience with a caring, nurturing approach. Unfortunately, however, there are situations where faculty treat students in an uncivil manner. Conversely, certain student behaviors are considered uncivil toward faculty.

Faculty and Student Behavior Considered to Be Uncivil

This was addressed in the chapter on classroom behavior. However, it warrants additional acknowledgement. Academic incivility impairs the student–faculty relationship and the learning environment. Toxicity from the classroom can then also impair the clinical arena. Faculty have a responsibility to provide an environment that is conducive for learning. By fostering a relationship that is ﬁ rm and authorita- tive but demonstrates respect and caring of the adult learner, the faculty and student can respect the diversity of one another and learn to care for others with the same respect role modeled in the clinical environment.

What About Faculty That Tip the Scale and Want to Be Everyone’s Best Friend?

I am sure that all seasoned nurse educators can provide examples of situations in which coworkers have perhaps blurred the boundaries between the faculty and student relationship. Specifi cally, students should formally address faculty at all times (not using fi rst names) and there should be only superfi cial discussion regarding personal lives. Of course some students come to faculty to inform them of situations occurring in their lives for advising purposes; however, no personal advice should be offered to students. Most schools offer counselors in the Student Support Services division and that is the most appropriate referral for students needing personal 66 4 Clinical Experiences assistance. I have personally witnessed faculty discussing attendance at a student party (where drinking was involved). Faculty naturally want students to “like them” and such approval from students translates to course evaluations. However, faculty must refl ect on their own teaching practices and refrain from blurring of the bound- ary lines. Approval from students should not be the end goal; rather, stellar teaching practices resulting in outstanding patient care should be the goal. Usually if faculty operate with the latter as the goal using a caring, nurturing approach, the end of course evaluations will refl ect positively.

Scenario Eight: Promoting Professionalism in Our Students

Cassy is the skills lab director and she is known for her rather inappropriate behavior in the skills lab environment. She has long ﬁ ngernails that are always painted; allows her cell phone to ring (and answers it) during the lab session; and walks around the “patient care areas” with her drink. Rebecca began to notice that students in the lab were modeling the behaviors that have been observed from Cassy. When she discussed this with Cassy, she responded by stating that she is sure that the students are not exhibiting this behavior at the hospital because the students know the difference. Key Issue: The key issue in this scenario is a basic understanding of the importance of professional modeling behaviors by all faculty in order to promote this behavior in the students.

Conclusion

Teaching in the clinical area can be the most challenging yet rewarding experience for faculty. The high points range from witnessing the light bulb that shines when a student who has learnt an important concept is able to translate the knowledge learned in the classroom to the clinical area to the student able to recognize a change in the patient’s condition and implement the correct sequence of interventions. The lows may range from having to give a student an “unsatisfactory” in clinical due to a uncivil interaction with a patient or the student explaining how they are not interested in learning from the clinical experience. A respectful learning environment is key to the interaction of the faculty and student. As discussed, successful clinical faculty exhibit similar characteristics: available and approachable; provide timely, constructive feedback; promote critical thinking; receptive and respectful; organized; and humble. References 67

References

Baldisseri, M.R. Impaired Healthcare Professional. Critical Care Medicine. 2007;35(2): S106–S116. Benner P, Sutphen M, Leonard V, Day L. Educating nurses: A call for radical transformation. San Francisco: Wiley; 2010. Brookfi eld SD. The skillful teacher: On technique, trust, and responsiveness in the classroom. San Francisco, CA: Jossey-Bass; 2006. Chan S, Wai-Tong C. Implementing contract learning in a clinical context: Report on a study. Journal of Advanced Nursing. 2000;31(2):298–305. Dillon R, Stines P. A phenomenological study of faculty-student caring interactions. Journal of Nursing Education. 1996;35(3):113–8. Gaberson KB, Shellenbarger T, Oermann MH. Clinical teaching strategies in nursing. New York: Springer Publishing Company; 2015. Hills C, Boshoff K. The future of their hands: The perceptions of practice educators on the strengths and challenges of “Generation Y” occupational therapy students. The Open Journal of Occupational Therapy. 2015;3(4):1–16. Hutchinson D, Brown J, Longworth K. Attracting and maintaining the Y generation in nursing. Journal of Nursing Management. 2012;20:444–50. McAllister M. Learning contracts: An Australian experience. Nurse Education Today. 1996;16:199–205. Montenery SM, Walker M, Sorensen E, Thompson R, Kirklin D, White R, et al. Millennial generation student nurses' perceptions of the impact of multiple technologies on learning. Nursing Education Perspectives. 2013;34(6):405–9. Murphy-Parker D. Implementing policy for substance-related disorders In Schools of Nursing: The right thing to do. Dean’s Notes. 2013;34(5):1–3. Retrieved July 30, 2016, from CINAHL Complete, Ipswich, MA. Rogers C. Freedom to learn for the 80’s. Columbus: Merrill; 1983. Tanicala ML, Scheffer BK, Roberts MS. Defi ning pass/fail nursing student clinical behaviors phase I: Moving toward a culture of safety. Nursing Education Perspectives. 2011;32(3):155– 61. doi: 10.5480/1536-5026-32.3.155 . Walker J, Martin T, White J, Elliott R, Norwood A, Mangum C, et al. Generational (age) differences in nursing students’ preferences for teaching methods. Journal of Nursing Education. 2006;45(9):371–4. Wan Yim I, Lui MH, Wai Tong C, Lee IF, Lai Wah L, Lee DT. Promoting self-refl ection in clinical practice among Chinese nursing undergraduates in Hong Kong. Contemporary Nurse: A Journal for the Australian Nursing Profession. 2012;41(2):253–62. Chapter 5 Simulation

An Educator’s Perspective

Vicki Moran

As a faculty member I am always challenged with the question of how can I teach students to think like a nurse? Several years ago, I was involved in developing simulation sessions within our curriculum. We created simulations for every area of nursing, from medical surgical to public health. When we fi rst sat down as a group, many of us had simulation ideas but not sure how to implement them. The faculty who was teaching the assessment course shared how they had used anatomical body part models to assist with Foley catheter insertion and IV catheter insertion. However, the rest of the group was challenged on what was actually needed for the simulation. During our sessions, we discussed what was needed to create a simulated environment. These included a patient, all the necessary equipment, and writing a script or scenario. Each faculty member started to think about what they were interested in teaching for simulation. After several meetings, many of the simulation examples focused on patients’ that had really challenged the student’s critical thinking ability while in the clinical setting. The fi ve-member group worked to create fi ve different simulations. The group was collaborative and supportive focusing on important details necessary for each simulation. We created a simulation for medical surgical nursing, pediatrics, obstetrics, advanced medical surgical, and public health. We used a variety of patients with each simulation but each simulation had background reading and clinical preparation paperwork that needed to be completed prior to coming to the simulation. Students were expected to have prepared for the simulation, wear their scrubs to the simulation, and be ready to discuss what went right and wrong. During the fi rst year, we created the simulation, and we found many mistakes and problems with the simulation. The fi rst year of implementation of the simulation experiences, we used live actors or even live faculty members. Often times, the actors and even some of the faculty failed to prepare for the simulation experience.

They would give the wrong information about themselves as the patient, which confused the students. So we quickly realized how important it was to prepare the actors for the simulation and to use the same actors for the simulations each time. Another mistake was not allowing for students to document assessment, intervention, and evaluation measures. This was a fundamental mistake and we soon realized how important this was to the simulation process. Each simulation used a different charting record so we soon realized we needed to streamline this as quickly as possible. Use of a computerized charting system was initiated after the fi rst year of the implementation of the simulations. This was a huge burden lifted from all members of the group. With the use of a computerized system, it was easy to create “similar” patients but with different names. Students then would not have the same simulation and know exactly what to do during the simulation. The purpose of this chapter is to assist with the development and implementation of simulation in a nursing curriculum and focusing on the critical elements necessary for a simulation experience. Simulation is a teaching strategy where theory and role modeling come together to allow students to practice nursing in a setting that closely mimics the clinical environment. The infusion of simulation has been documented across nursing programs. The rapid growth of simulation is driven by a variety of factors, including increased competition for clinical settings between nursing programs and shortages of nursing faculty. There has also been an increase in technology supporting simulation. These range from simulations performed on the computer to high fi delity mannequins that blink and talk. The National Council of State Boards of Nursing (NCSBN) Simulation Study results support the fact that simulation can be substituted for traditional clinical placements (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014 ). Simulation is a means to evaluate nursing care in a safe environment without causing harm to a patient. In the simulation environment, nursing students are assigned roles of a simulated patient scenario to determine nursing interventions and evaluate patient responses. A variety of roles are used with an emphasis of communication skills within the scenario. Research has shown that simulation-based training has improved student learning and quality of patient care (Cant & Cooper, 2014). Because of these benefi ts, many nursing programs allow for some level of simulation as a clinical substitute (Hayden, Smiley, & Gross, 2014 ). There are several pedagogies that serve as a theoretical framework for simulation. Different nursing schools use different theories as foundations for simulation in their curricula. For this reason, it is imperative that you learn your school’s theory. The most common theoretical framework is Benner’s description of the Dreyfus Model of skill acquisition. This framework describes fi ve stages of development toward nursing expertise: • Stage 1 is the novice stage, where beginners have no experience of the situations in which they are to perform (Benner, 2001 ). Concepts and skills are learned in isolation and have very little implications for practice. • Stage 2 is the advanced beginner. In this stage, aspects or attributes are required and have been used by the beginner (Benner, 2001 ). The nurse or student must have prior experience to be in this stage. In this stage, the student or nurse is An Educator’s Perspective 71

completing tasks without completely understanding why he or she is completing the tasks. • Stage 3 is competent . The nurse or student is comfortable with performing and has been in the role for 2–3 years. They begin to see their actions in terms of long-range plans. The nurse or student understands the plan and is able to carry out the plan. • Stage 4 (profi cient) and Stage 5 (expert) are reserved for those nurses who have full understanding of the clinical picture and are able to communicate this to the patient and other healthcare providers. Rarely is a nursing student able to reach these stages. Simulation provides a safe venue for classroom learning and clinical experience to align. The student learns necessary knowledge and skills and then is able to perform nursing interventions and evaluate the care in an environment that encourages open communication. Simulation is also described as experiential learning. A student learns by practicing learned nursing assessment and interventions on simulated patients in a simulated health care environment. It creates a clinical environment where teaching and learning from the classroom can be assessed. Other learning theories that simulation provides includes change theory, problem-based learning, constructivism, and self-effi cacy (Hallmark, 2015 ; Rourke, Schmidt, & Garga, 2010 ; Thomas et al., 2015 ). Additionally, simulation incorporates six adult learning principles: “1. adults need to know why they need to learn something before learning it; 2. adults want to be self-directing in their learning; 3. adults have rich past experiences which shape their current learning; 4. learning needs to be temporally related to real-world application; 5. orientation to learning needs to be task-centered not subject-centered; and 6. internal motivators are important for adult learners” (Holt et al., 2013 , p. 1276).” These theories can drive the background or the focus of how students learn and perform in the simulated environment. Simulation can be used in all clinical courses in a curriculum—using a variety of different simulation environments: low, medium, and high fi delity. Low fi delity simulation environment is the use of case studies or limb based manikins. These simulate an environment with a realistic, life like look. Examples can include wound areas to practice applying a wet to dry dressing change or pelvic area for urinary catheter insertion. Medium fi delity simulation environments use more realism. Examples include a manikin that takes a breath in during bag mask ventilation or a live actor trained to follow a prescribed script. High fi delity simulation environment provides the most realistic experience by using a computer-based manikin. The manikin responds either by control of an actual person or it is scripted to perform a certain way with various interventions. A variety of simulation environments can be used in the nursing curriculum. Newer in the simulation environment is the computer-based simulation. Using a computer program, a nursing student has access to a simulated patient on the computer and uses the mouse to navigate in the electronic health record. The computer- based program also allows for the attainment of other skills by clicking the mouse 72 5 Simulation

Fig. 5.1 Bloom’s taxonomy. Photo credit given to https://cft.vanderbilt.edu/guides-sub-pages/ blooms-taxonomy/ such as taking a blood pressure and heart rate to complete an assessment and document the fi ndings. This newer program can provide additional simulation experience and can be of assistance to schools that may not have the space and fi nancial resources for a simulation area. What are the Nuts and Bolts for preparing for simulation? 1. Idea for the simulation. The fi rst step is to identify what you would like the students to learn; begin with the endpoint in mind. This can be as simple as return demonstration of insertion of a urinary catheter or as complex as a simulation that involves the student navigating assessment and interventions for a patient with multiple, overlapping comorbidities and complex psychosocial needs. Using low, medium, and high fi delity simulators a variety of choices exist. However, I recommend using low and medium simulators for beginning learners. The rationale behind that is to introduce the learner to the simulation environment by using simple skills or assessments to build confi dence in the learning environment. 2. Write learning objectives. The simulation objectives should be written in a way that is similar to the objectives that might be used in a classroom setting. The objectives should be clearly written to measure the learning of the students. A minimum of three objectives is a good starting point and they must be appropriate to the level of the student. For example, beginning level learners should have objectives that match performance at a foundational level. Most faculty use Bloom’s taxonomy to write the objectives (Fig. 5.1 ). 3. Script the simulation. After identifying the learning objectives, write a script of the simulation. If a return demonstration is necessary, a short scenario providing a realistic context for the skill should be read to the student. The student can then decide which intervention to perform. For more complex simulations, a script is necessary to describe the course of events and prepare for the use of a high fi delity An Educator’s Perspective 73

simulator. Equipment and personnel should also be specifi ed in the script to ease the preparation of the simulation laboratory staff or other simulation faculty. 4. Prepare the student . The faculty should be prepared to provide the student with pre-simulation learning about a certain skill or illness. This provides active preparation of the learner. In addition, the use of videos can also aid in the preparing the student for the simulation. This pre-simulation learning should be provided to students well in advance of the simulation session. 5. Manage the simulation. Students should be given a preliminary introduction and background before the session. Roles can be randomly assigned and generally include the primary and secondary nurse, nursing supervisor, and visitor. The other students involved in the session can be assigned the role of observers and view the session from either a “streamed” video room or in the control room. Students participating in the session should be given an orientation to the resources available and special instructions if necessary. The faculty should orient the student to the simulation which includes the use of a computer for charting, use of non invasive blood pressure cuffs, thermometers and the like. By orienting the student, the student feels more confi dent to manage the simulation environment. During the session, students can work together to aid in communication, nursing interventions, and evaluation of the patient. At the end of the session, the groups of students can switch roles. 6. Debrief the simulation with the student and with other faculty. Imperative to the integration of simulation are the scenarios and debriefi ng. Every clinical course can use a variety of scenarios to simulate a clinical issue. Debriefi ng is the most important technique of the simulation as it clarifi es, amplifi es and highlights challenges of the simulation experience (Duphiley, 2014 ). Debriefi ng is:

an activity that follows a simulation experience and is led by the facilitator. Participants’ Refl ective thinking is encouraged, and feedback is provided regarding the participants’ Performance while various aspects of the completed simulation are discussed (Gore & Thomson, 2016 , p. 88). Through their own refl ection of the session, students are able to gain insight and clarify gaps in their knowledge. The students are able to identify what they did right and identify ways to improve. Debriefi ng also allows each student to refl ect on the actions and behaviors of the other students. If the capabilities exist, video of both simulation sessions can be viewed by the students and the students can view each other. Debriefi ng also allows nursing students to feel that their opinions and insights matter (Duphiley, 2014 ). This lays the foundation for professionalism, where a student is able to grow into the knowledge, skills, and attributes of a nurse. A sample of debriefi ng questions is listed in Appendix L . The National League for Nursing (NLN) and the International Nursing Association for Clinical Simulation and Learning (INACSL) collaborated recently in a paper discussing the importance of debriefi ng across the curriculum: “Evaluation of the debriefi ng environment ensures that the overall learning experience contrib- utes to meeting course and/or program outcomes” (NLN, 2015 ). The authors support also using a debriefi ng assessment tool and recommend the most commonly 74 5 Simulation used tool in nursing education, the Debriefi ng Assessment for Simulation in Healthcare (DASH) (NLN, 2015 ). Evaluation of the student’s performance in the simulation should be included in the formative evaluation. This can be achieved in a variety of ways. If the simulation is used for additional clinical learning, the performance including the simulation activity and the debriefi ng interaction should be evaluated with the student. If the simulation is used for clinical, then the debriefi ng performance as well as the simulation performance should be included in the clinical evaluation. The evaluation, in both cases, provides feedback for student learning. This is refl ective practice for the educator and for student learning. In addition, evaluation of the simulation should also be included in the summative evaluation of the course and clinical. This provides added value to describe the benefi t and challenges of simulation in a nursing course and in the nursing curriculum.

Scenario One: Basics of Simulation Preparation

Cloe has been asked to fi ll in for a faculty member who will be out on maternity leave. She has been a clinical faculty for the past 3 years but has only facilitated a few simulation scenarios. She is not quite sure where to begin. How to Prepare for a High Fidelity Simulation . It is important that the simulation environment “looks” and “feels” similar to the real hospital environment. Simulation should mirror the healthcare environment as much as possible. In order for this to happen, faculty must make all necessary preparations. According to Willhaus (2016 ), realism (or fi delity) is established when high fi delity simulators are used. High fi delity simulators have the ability to breathe, tear up, talk, sweat; whereas, low fi delity simulators do not have these capabilities. Additionally, faculty should make every effort to mimic the real environment through smell, sound, and light. For example, in order to mimic evisceration, I did the following: I took several knee high stockings and stuffed them full of play dough and then covered them with red food coloring (Fig. 5.2). I then placed them on the simulators abdominal wall and covered this with an ABD pad (dressing). The students were involved in a scenario where an assessment was in the process of being performed when the patient coughed hard enough to eviscerate. The student had to fi gure out that the evisceration occurred and then process through the priority nursing action. The sky is the limit with moulage, and this is a prime opportunity to be creative! Another important aspect of the simulation environment is faculty preparation. Faculty must take time to practice the scenario a few times prior to involvement with students in order to make it feel natural. Starts and stops during the scenario because of lack of practice make the scenario less natural. Faculty must also make sure that all parts of the scenario are appropriate. For example, the patient armband must match the medical record and any medications necessary for the scenario must be available and appropriately marked. It is not appropriate during the scenario to An Educator’s Perspective 75

Fig. 5.2 Simulation photo

tell the students to pretend, for example, that a bag of fl uids is heparin when it is marked as normal saline. Students must be provided an opportunity to appropriately negotiate through the fi ve rights of medication administration, etc. As previously stated, faculty should consider sending a pre simulation reading assignment along with the learning objectives of the simulation scenario. Some may choose to provide a quiz and students must bring the quiz as a “ticket to enter” the simulation event. The students should not have access to the scenario prior to the simulation. When students enter the lab, there should be a discussion to prepare them for their scenario. This discussion should include a statement regarding the fact that simulation is considered a safe environment. Students should be reminded that they are to behave in a manner as if they were in the hospital setting. They should be led into the simulation room and provided information regarding their environment: location of supplies, name of the patient, how to turn equipment on in the room, etc. Next, students should be led out of the simulation room and provided their simulation roles. These roles may include but are not limited to: primary nurse, medication nurse, intervention nurse, observers. Sometimes the students are asked to play the role of the family members and are provided the scripts. Many schools are using interdisciplinary scenarios and are incorporating students from other professions such as respiratory therapy, physical therapy, and medicine (Willhaus, 2016 ). Just prior to starting the scenario, students should be informed regarding the length of time for the scenario (Principle 5). They should also be told that time will be called when the alarm rings and this does not indicative of anything good or bad occurring in the scenario; rather, it is simply time for the debriefi ng session. The next piece is probably one of the most diffi cult for faculty to adhere to—and that is that faculty should allow the scenario to unfold without intervention. The debriefi ng session is the time when all involved during the scenario have the opportunity to discuss what worked well and where the opportunities for improvement exist. During the scenario, however, faculty should be document observations to be 76 5 Simulation

discussed during the debrieﬁ ng session. This includes details such as effective hand washing; appropriate communication to include introductions; effective use of the rights of medication administration; providing the call light to the patient; effective use of the white board (in the patient’s room). The faculty must determine how these observations will translate into evaluation of student performance. Philosophical discussions should take place regarding the application of a grade to the simulation environment. Remember, simulation should be a safe place for learning to take place. Are students able to optimally perform and critically think when there is a letter grade assigned to their performance? According to Roykenes, Smith, and Larsen (2014 ), “test anxiety affects the learning, performance and well-being of students, and it increases as the stakes get higher” (p. 350). Debrieﬁ ng (discussed later in the chapter) is an opportunity for the faculty and students to dialogue regarding the events that took place during the simulation scenario.

Scenario Two: Students that are Unprepared

Susan, and her fellow classmates, were debrieﬁ ng after simulation. Susan mentioned during the debrieﬁ ng that she was completely unaware of the admitting diagnosis of the medical surgical patient they cared for. Missy, the clinical faculty, waited until after the simulation was over and discussed this with Susan. Susan admitted that she did not read any of the assigned pre-simulation material, stating that she preferred to “think on her toes.” Key Issue: Preparing for simulation is just as important as preparing for clinical. Ideally, all students should have read the simulation material and prepared by researching the medical history, surgical history, medications, and psychosocial issues prior to patient care. Doing so prepares the student to deliver safe and appropriate care. This is in alignment with Principle 3, encouraging active learning, and Principle 6, communicating high expectations. Nursing faculty need to make sure that the students are prepared, possibly by providing a nursing preparation tool and nursing diagnosis form for students to complete prior to the simulation experience. Immediately following simulation, students should be given feedback on their performance. Failure to provide the feedback on their performance can inhibit their desire to learn how to improve. This also correlates Principle 4, giving student prompt feedback. In addition to feedback, students should be reminded that this is a simulated experience which can be replaced with clinical experience. Therefore, students should view simulation as being every bit as serious and valuable as clinical.

Scenario Three: Letting a Student Fail

This was Mark’s fi rst semester in nursing school. He was completely overwhelmed with the amount of clinical work and studying required by nursing school. He visited two of his faculty weekly but was still frustrated with the low grades he had An Educator’s Perspective 77 been receiving. After the fi rst simulation, he was hesitant about participating in the simulation and debriefi ng. His faculty gave him feedback about his apprehension and suggested a few ways to feel more confi dent and to be more involved in the simulation. The faculty reported the behavior to the course coordinator and provided a detailed description including suggestions for improvement. After the second simulation during the semester, Mark was not engaged in either simulation or debriefi ng. The faculty member again provided feedback immediately to Mark and reported verbally and in writing the issues with the simulation and debriefi ng. The course coordinator and Mark met to discuss grades and the simulation experience. Even Though Mark acted interested during the appointment, he identifi ed issues of not wanting to be a nurse, especially during the simulation experience. Key Issue: All the right messages were given in the scenario but the problem was the student. The student was genuinely not interested. This was evidenced by his lack of participation in simulation and his low grades. Faculty need to be satisfi ed with a student that lacks the desire. A faculty’s job is to create a professional who is interested in a career path of caring for patients. It is the duty of the faculty to recognize those that cannot succeed and steer them differently. This does not mean to encourage all to leave but an educator needs to develop a genuine interest for the student and their life is important. This genuine interest is in alignment with Principle 1, encouraging contact between the student and faculty. If a student lacks the drive, then faculty should initiate the conversation of the consequences of failure in the course and maybe the program. Faculty should not be afraid of discussing issues of performance with the student. By giving prompt feedback on performance (Principle 4), a student and faculty are working together to achieve the expectations of the learning environment (Principle 1 and 6). Faculty should also be aware of their need to “rescue” the student. Often times, faculty feel that they need to step in and assist the student with their study habits, their performance, and their ability to perform in clinical or simulation. The student needs to be engaged otherwise the natural desire to learn and become a professional is half heartedly pursued. Engagement is encouraged by the active learning environment.

Scenario Four: Reducing the Anxiety of Simulation

Sam was extremely nervous about the simulation. She had met with the course coordinator at the beginning of the semester and also the week before the simulation experience. She was saying how “I am so confused as to why we need to do this. What do I do?” The course coordinator as well as her clinical faculty addressed her questions with conﬁ dence and explained how simulation works and what was expected. However, Sam continued to experience anxiety and 1 h before the simulation was to begin, Sam was crying in another faculty member’s ofﬁ ce about how nervous she was. Key Issue : The key issue expressed in this scenario is the stress that students can feel as a result of simulation. 78 5 Simulation

What Can Faculty Do to Alleviate the Anxiety? A study conducted by Najjar, Lyman, and Miehl (2015 ) revealed common themes regarding students’ descriptions of the simulation experience. Anxiety and fear was reported by every student in the study. Students reported feeling “overwhelmed” (p. 3) and felt that it was diffi cult feeling like they had to perform. Anxiety was also present because the students felt they were not profi cient with the use of the simulation equipment. Additionally, the unpredictability of the unfolding scenario led to pronounced anxiety. It is imperative that faculty provide explicit details about the simulation experience and the expected behaviors. In this case, the class should have been introduced to the simulation environment and watch a brief simulation session including a debriefi ng. Prior to any simulation session, students should be oriented to the simulation environment so they can acclimate themselves. Course, clinical and simulation expectations should be shared and discussed during orientation (Principle 6). By doing so, the students are aware of the expectation for the simulation experience (Principle 6). If a student is still having issues related to anxiety, the faculty should refer them to student counseling services. If the student is having diffi culty with preparation in class or simulation, peer tutoring is encouraged. All in all, listening to the student and using techniques described can reduce anxiety and allow for a successful simulation experience. Other themes emerging from the study by Najjar et al. (2015 ) include: “emotional processing, making connections, fi delity, and learning” (p. 3). The fi rst theme, emotional processing, “is defi ned as the active working through the emotions emerging as part of the simulation experience which included anxiety and fear” (p. 3). Students felt challenged to process emotions and such processing was necessary prior to being able to critically think. Faculty are key to this process and, as previously stated, they must do everything possible to alleviate anxiety and fear prior to the initiation of the scenario. The second theme, making connections, implies the student’s ability to negotiate the current scenario and apply and make connections to prior experiences in the clinical setting, skills lab, or classroom. Faculty can facilitate the students’ experiences by clearly delineating the simulation objectives and making sure that there is a clear link between the classroom and clinical experiences. The third theme, fi delity, refers to “the believability or realism of a simulation scenario” (p. 4). Students felt uncomfortable when the manikin’s facial expressions were incongruent with the scenario. This, according to the feedback from the students in the study, impacted the reality of the simulation and thus impeded the effectiveness of the learning environment. The fourth and fi nal theme, learning, refers to the “transference of learning improved across clinical and simulation as students progressed through their nursing program” (p. 6). Students knowledge and learning was positively impacted through the ability to watch others during the simulation experience.

Conclusion

Simulation is another teaching modality that can prepare nursing students to care for simulated clients in a safe environment; and if utilized properly, it can be utilized to support reduced clinical hours by schools of nursing. Therefore, it is imperative References 79 that nursing educators know how to adequately prepare nursing students for the experience and participate in the simulation session. Faculty should apprise themselves of faculty development opportunities in order to ensure consistency in the simulation environment. In order to promote learning in the simulated environment, faculty should ensure that the principles of effective simulation are utilized.

References

Benner P. From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Health; 2001. Cant R, Cooper S. Simulation in the Internet age: The place of web-based simulation in nursing education. An integrative review. Nurse Education Today. 2014;34:1435–42. Duphiley NH. Simulation education: A primer for professionalism. Teaching and Learning in Nursing. 2014;9:126–9. Gore T, Thomson W. Use of simulation in undergraduate and graduate education. AACN Advanced Critical Care. 2016;27(1):86–95. Hallmark B. Faculty development in simulation education. Nursing Clinics of North America. 2015;50:389–97. Hayden JK, Smiley RA, Alexander M, Kardong-Edgren S, Jeffries PR. Supplement: The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation. 2014a;5(2):C1–S64. Hayden JK, Smiley RA, Gross L. Simulation in nursing education: Current regulations and practices. Journal of Nursing Regulation. 2014b;5(2):25–30. Holt RL, Tofi l NM, Hurst C, Youngblood AO, Peterson DT, Zinkan JL, et al. Utilizing high-fi delity crucial conversation simulation in genetic counseling training. American Journal of Medical Genetics A. 2013;161A:1273–5. Najjar RH, Lyman B, Miehl N. Nursing students’ experiences with high-fi delity simulation. International Journal of Nursing Education Scholarship. 2015;12(1):1–9. NLN. (2015). Debriefi ng across the curriculum: A living document from the National League for Nursing in collaboration with the International Nursing Association for Clinical Simulation and Learning. Retrieved from http://www.nln.org/docs/default-source/about/nln-vision-series- (position-statements)/nln-vision-debriefi ng-across-the-curriculum.pdf?sfvrsn=0 . Rourke L, Schmidt M, Garga N. Theory-based research of high fi delity simulation use in nursing education: A review of the literature. International Journal of Nursing Education Scholarship. 2010;7(1):1–14. Roykenes K, Smith K, Larsen TM. It is the situation that makes it diffi cult: Experiences of nursing students faced with high-stakes drug calculation test. Nurse Education in Practice. 2014;14(4):350–6. Thomas C, Sievers L, Kellgren M, Manning S, Rojas D, Gamblian V. Developing a theory-based simulation educator resource. Nursing Education Perspectives. 2015;36(5):340–2. Willhaus J. Simulation basics: How to conduct a high-fi delity simulation. AACN Advanced Critical Care. 2016;27(1):71–7. Chapter 6 Online Learning

An Educator’s Perspective

Jeffery M. Dyck

In the fall of 2008, our nursing department received an edict from the government department of education that there was to be a fundamental restructuring of our Bachelor of Science in Nursing program, which at that time was a blocked, content- based curriculum. Rumors abounded that this change had everything to do with external politics and little to do with educational concerns. Nonetheless, it had to be done. Firstly, we were required to compress our program from 3.5 calendar years down to 3 years, while maintaining the same number of course credits and clinical hours. Secondly, it was determined by administration that some of the courses that had long been offered in a traditional classroom format were to be offered in a fully online format. These were just two among many changes, and it was required that all of these changes be in place for the student cohort that was scheduled to begin the program in only 6 months. Needless to say, a fl urry of academic activity ensued and the tight timeline made it diffi cult to conduct the process with all the rigor that it deserved. I was chosen to oversee the development of one of the new courses that was being added to the curriculum, as well as taking a preexisting classroom course on nursing research and “putting it online.” I clearly remember this directive, which seemed to imply that all of the requisite material was already at my fi ngertips and that all I had to do was to shovel the course content from one bucket into another, and then go for coffee. In reality, I felt like I was being told to learn how to speak a new foreign language this weekend. After voicing my concerns, some of my colleagues assured me that I was certainly qualifi ed for this undertaking since I was “good with computers.” I have a vivid memory of a colleague who had most recently been teaching this course asking, “Can I bring by my course materials for the research course?” I agreed, of course, and then promptly took delivery of three “bank- er’s boxes” containing hundreds, if not thousands, of documents, handouts, learning

© Springer International Publishing Switzerland 2016 81 K.C. Harmon et al., Nurse Educator’s Guide to Best Teaching Practice, DOI 10.1007/978-3-319-42539-9_6 82 6 Online Learning activities and exams. My colleague assured me, “Don’t worry—I’ve got most of this on a Flash drive for you as well.” I wasn’t sure whether to laugh or cry. Unable to decide, I may have in fact done both. Fortunately, I was able to get full release from my usual teaching responsibilities in the clinical and classroom settings. I quickly became dependent on the exceedingly capable and patient Instructional Design Consultants (IDCs) in my institution’s Teaching and Learning Centre. To my relief, these consultants were veterans at this process, having assisted faculty members from diverse departments with similar transitions in course delivery. It became readily apparent that the idea of putting a classroom course online was a misnomer. In many ways, the boxes of paper-based handouts and the electronic documents that had been used in our program’s nursing research course turned out to be a problem rather than a solution. The process didn’t just involve the transfer of course materials; it required the wholesale creation of a new course. The existing course outcomes were certainly amenable to an online format, but the learning activities and the evaluation components were an awkward fi t, at best. In the end, I was able to appropriate and adapt some of them, but a large majority of the course materials had to be created. Simultaneously, I was climbing a steep learning curve in order to become familiar with the institution’s learning management system (LMS)— the software platform on which all of the online courses were hosted. This added an unprecedented layer of complexity to the course development process, one that I had never needed to consider when involved in earlier course development projects. With the adept coaching of the IDCs, though, I was able to transition from seeing the LMS as a problem that had to be solved to seeing it as a tool to facilitate course design and, ultimately, student learning. More on that in the subsequent portions of this chapter. The second course that I was charged with creating focused on evidence-based practice. At the time, I had just fi nished creating the test generator and some of the other ancillary products for a new textbook on EBP that was soon to be released. I was able to draw on several months of close engagement with the subject matter of the course, and this familiarity certainly expedited the course development process. For 5 months, I worked on nothing but these two courses, and they were able to withstand peer review and an appraisal by our school’s curriculum committee, even- tually going live on the exact date that they needed to. I had similar feelings when I sent my oldest child off to kindergarten for the fi rst time. I was the course leader for one of the courses during the fi rst offerings, and I frequently found myself somewhat bewildered by teaching in this domain that was new to me in an instructor role. I had focused on nursing education in my master's degree, but there was very little that I could apply to this context. Students’ learning styles and learning preferences had certainly not changed through the introduction of online delivery, but the knowledge and skills that I had previously applied to planning learning activities seemed to be rendered moot by online delivery. In many schools of nursing, there is a brief orientation course that is offered to new instructors. If this is offered by the larger institution, it usually focuses on classroom teaching ; if offered by the school of nursing, it often supplements this with instruction on how to be an effective clinical teacher. In the case of online teaching, however, there was nothing in place at that time in my institution. Working with the An Educator’s Perspective 83 instructional design consultants, I had become reasonably adept at using our chosen LMS, and there seemed to be an assumption that this constituted orientation to online teaching. This assumption highlighted one of the axioms of becoming oriented to online teaching: effective online education requires much more than just a familiarity with the software! All online education takes place in the domain of that software, but just because an instructor is adept at that software does not necessarily guarantee that he or she is skilled at facilitating online education. Circumstances forced me into a version of self-orientation. Even more, I was charged with orienting some of the other new instructors who would also teach some of these new online course offerings. Some of the early challenges that I faced are common to those faced by instructors today who are faced with teaching online for the fi rst time: learning how to engage students in the electronic domain; establishing rapport; mastering new technology; addressing academic dishonesty and, ultimately, determining whether learning outcomes are being achieved. In the end, both courses received positive evaluations from students and from the instructors who taught them. As with any course, revisions were necessary on an ongoing basis but especially after the fi rst one or two offerings. Both courses have since been supplanted during the implementation of a concept-based curriculum, but online delivery remains a cornerstone of our undergraduate and specialty nursing programs. In just a few short years, online delivery has gone from being a rumor, to an exotic novelty, to a cornerstone of content delivery in most nursing programs. In this chapter, several of the most common and signifi cant challenges that nursing instructors face when teaching in the online domain will be discussed. The purpose of the discussion will be twofold: fi rstly, it will validate and normalize some of the issues that online instructors face, especially those who are new to online instruction; secondly, it will provide practical strategies for addressing these issues. Approaches will be suggested for some of the pressing questions that the editors have experienced fi rst- hand and have been asked by instructors who are new to an online setting: • How can I get up to speed on my school’s learning management system (LMS)? • How can I keep the students engaged? • How can I develop community in an online setting? • How can I best deal with academic dishonesty? • How can I ensure I don’t become isolated?

Scenario One: How Can I Best Get Up to Speed on My School’s LMS?

Kyle considers himself to be an expert nurse. After working in what he describes as “dead end jobs” for 3 years after graduating high school, he applied to an ADN program at his local community college. His girlfriend at the time was a practical nurse on a medical-surgical unit and Kyle says, “Every day she came home with the most fascinating stories, and that solidifi ed for me that I had to look into nursing as 84 6 Online Learning a career option.” Kyle excelled in his ADN program, not only getting good grades but receiving exemplary evaluations on his clinical performance. He graduated on time, passed the NCLEX on his fi rst attempt and was able to secure a job on an acute medicine unit, aided by a clinical instructor’s glowing recommendation. Kyle worked for 4 years on the medicine unit. He jokes, “For the fi rst year, I felt like getting over imposter syndrome was my full-time job, so in my head I’ve got it chalked up as only 3 years!” During this time, Kyle took on charge duty on an increasingly frequent basis and broadened his clinical exposure by fl oating to a variety of units, including cardiac care, burns and plastics, and acute care for elders. His most salient experiences, he says, involved two types of interactions: the groups of nursing students that constantly rotated through the unit and the four times that he was able to preceptor senior nursing students. Kyle says that these experiences pulled his thinking away from specializing in a higher acuity setting and towards nursing education. He was accepted into an RN to BSN program and changed his full-time line to casual status so that he could juggle academics with the need to work shifts and pay the bills. He describes the process as “grueling,” but eighteen months later he got his BSN. Knowing that he wanted to pursue nursing education, he spoke at length with the instructors in his BSN program, who unanimously encouraged him to pursue a Master of Science in Nursing as soon as possible. Ignoring the cautions of some of his coworkers, Kyle applied to an MSN program during his last semester of the BSN program and transitioned immediately into graduate studies, still working an average of two to three 12-h shifts each week. His university offered an education track, and he chose a thesis option for the purposes of leaving the door open for doctoral studies at some point in the future. Kyle is now in the fi nal semester of his MSN program. A few months back, the clinical instructor of one of the student groups that was placed on his unit encouraged him to check out her college’s job vacancies posted online. She assured Kyle, “With your background and your clinical experience, you’re a shoo-in.” Armed with his updated CV and references from both his manager and two of the professors in his graduate program, Kyle uploaded an application to teach into the ADN and was contacted within days by a representative of the college’s human resources department. At the subsequent interview, Kyle was met by a panel of the HR representative, the program’s associate dean and a faculty representative from the staffi ng committee. He was informed that they were seeking someone to instruct full-time, divided between a clinical placement at a local hospital and an online course in pharmacology. After contacting his references, the HR rep has come back to Kyle with a written offer of a contract placement, starting in only 4 weeks. Kyle feels excited about the prospect of the clinical placement. Even though he has never worked at this particular facility, it is affi liated with his hospital and he knows one or two nurses who work there. But the online course? Kyle has taken some online courses in nursing theory, educational theory, and research methods during his MSN program and he admits that he found them to be “kind of a drudg- ery.” “Honestly,” he says “most of them really just came down to things like ‘read chapter 12 and post a comment.’ There was absolutely none of the stimulating ‘cross pollination’ that happened in the normal, face-to-face classes, which was really frustrating because I knew from our other courses that my classmates were passion- Prevalence and Growth of Online Courses in Nursing 85 ate, thoughtful nurses with this rich diversity of experiences and aspirations. In the online courses, all of that got basically fi ltered out by the online format.” “I don’t want the course I’m leading to be like that, but at the same time I’m at a loss for ways to actually change it. I don’t know who wrote and designed the courses. I don’t even know if they were designed by nursing educators, or if the people from the IT department put them together.” Kyle also describes how the university where he is doing his MSN uses a different platform from the college where he has been hired. “I’m computer savvy,” he states, “but it’s not like I’ll be using the programs and apps that I use in my own studies or in my day-to-day routine. Worse still, all of the students have already fi nished a couple of online courses by the time they start this pharm course, so it’s going to be like second nature to them while I’m fumbling around trying to fi gure out how to upload a document or link to a URL.” Key Issue : Kyle needs to become skilled in the use of his institution’s LMS in a short period of time It is not possible to effectively lead the learning process in an online environment without possessing familiarity and skill with the institution’s LMS. In light of this, it is curious that the nursing literature is nearly silent on the particular strategies and approaches with which novice educators can approach this task. This section of the chapter briefl y describes some of the strategies that instructors, like Kyle, can apply in their efforts to get “up to speed.”

Prevalence and Growth of Online Courses in Nursing

The most recent data indicate that in 2013, 70.7 % of degree-granting institutions in the USA offer some sort of online material (Allen & Seaman, 2014 ). The number of higher education students taking at least one distance education course in 2014 increased by 3.7 % over the previous year to over 5.2 million (Allen & Seaman). Despite the fact that this total represents the lowest rate of increase in a decade, it nonetheless demonstrates that online learning continues to grow. Within schools of nursing, data on the current prevalence of online delivery, both in terms of the numbers of programs that have online components and the proportion of online delivery within those programs, are elusive. However, research confi rms what nursing educators have likely observed: that they have proliferated in recent years (Carlon et al., 2012 ; Morgan & Hart, 2013 ). Online education presents students with unprecedented opportunities, most nota- bly increased fl exibility in the time and place of learning (Mayne & Wu, 2011 ). At the same time, they present a unique set of challenges, both for learners and instructors. For learners, some of the challenges identifi ed in the literature include the need to be self-directed with their time and energy, the lack of face-to-face contact with instructors, technical challenges and minimal interaction with their fellow students. For instructors, some of the major challenges include diffi culty in gauging students’ learning during the course (formative evaluation), not being able to get to know students on a personal basis, ensuring academic honesty, engaging students, and, as noted earlier, managing and navigating the LMS. 86 6 Online Learning

Instructors’ Perceptions of Feeling Unprepared

Any faculty member who is participating in online facilitation must feel comfortable with the necessary tools and technologies (Illinois Online Network [ION], n.d. ; Zsohar & Smith, 2008 ). Technological support is vital to the success of online nursing education (Pearsall et al., 2012 ). This corroborates what most nurses already know and have experienced: that it is not possible to perform a task without knowing how to use the necessary tools. And for online teaching, the toolbox consists primarily of familiarity with the LMS. Regardless of which LMS that the institution has adopted, the instructor must fi rst possess the basic skills of modern day academic life, including familiarity with major computer operating systems, word processing skills, the creation of tables, e-mail communication, manipulating folders, editing websites, and searching the Internet (ION, n.d.). For most faculty members, these tasks present few challenges, owing to their ubiquity in everyday life and in graduate nursing education. However, few faculty members approach their fi rst online teaching assignment having an equal level of familiarity with the LMS. As well, adeptness at using computers is not suffi cient on its own to prepare an instructor to effectively use an LMS (McAfooes, 2016 ). An LMS is defi ned as the infrastructure that delivers and manages instructional content, identifi es and assesses individual and organizational learning or training goals, tracks the progress towards meeting those goals, and collects and presents data for supervising the learning process of an organization as a whole (Szabo & Flesher, 2002 ). In a purely online environment, the LMS provides the setting for all electronic interactions between students and instructors and between students and the course content. The literature distinguishes between LMSs, course management systems (CMSs), and learning content management systems (LCMSs ) (Watson & Watson, 2007); however, a comparison of the similarities and differences between these concepts is beyond the scope of this chapter, and the term LMS is used throughout. The growth of LMSs mirrors the growth of computers in general and the Internet in particular. There are many LMSs available on the market and a few institutions have chosen to create and maintain an LMS in-house rather than purchase one from a vendor (Table 6.1 ). In their study of faculty members’ perceived barriers to online teaching Lloyd et al. ( 2012 ) identifi ed training and technology barriers as one of the four core categories of barriers faced by faculty members. Within this domain, inadequate instructor training, inadequate technology support and frequent technological fail- ures were cited among the most salient challenges. While these factors were not the most signifi cant challenges reported by participants, they are certainly among the fi r s t challenges faced by an instructor who is new to online teaching. In any other context of nursing education, the student is entering a domain in which the nursing instructor has vastly more experience, familiarity and—in most cases— confi dence. Nowhere is this more the case than in the clinical setting. Nursing instructors are intimately familiar with the norms, the processes, the sights, sounds and smells Instructors’ Perceptions of Feeling Unprepared 87

Table 6.1 Largest learning management systems by market shar e Market share by Market share students by enrolled institutions LMS Website (2015) (2015) Notes Blackboard www.blackboard.com 49.4 % 39.6 % ANGEL is (Blackboard scheduled to Learn; ANGEL) reach end-of- life in October, 2016 Instructure www.canvaslms.com 21.8 % 15.2 % (Canvas) Moodle www.moodle.org 16.9 % 20.6 % Free, open- source LMS Desire2Learn www.brightspace.com 13.6 % 9.1 % (Brightspace) Source: http://edutechnica.com/2015/10/10/lms-data-3rd-annual-update/ of the clinical setting, whether it be an inpatient hospital unit or a community-based client’s home . For many online nursing instructors, this dynamic is fl ipped. Many students are far more adept, and have a much more solid point of reference, in the online domain, despite the instructor’s mastery of the content. The instructor may be a master in the message, but the students may be masters in the medium. In many cases, a new instructor will be faced with the challenge of leading a course using a LMS that students may have been using since the beginning of their program. The instructor consequently fi nds himself or herself in the uncomfortable position of being the technological neophyte in the online community, and a neophyte that is commissioned with leadership responsibilities . Kyle’s readiness to learn and motivation to learn (Knowles, 1980 ) are clearly heightened, as he fi nds himself in a “sink or swim” scenario. This is common to many nursing instructors who are new to teaching and in more experiencing instructors who are faced with online teaching for the fi rst time. In light of these challenges, it is surprising how little evidence exists addressing the most effective and effi cient way to prepare new faculty for facilitating learning in the online domain. We propose some strategies that have worked for the editors and instructors with whom we have taught. Many of these strategies have a clear line of sight with the educational principles of Chickering & Gamson ( 1991 ) and Knowles (1980 ) that are introduced in Chap. 2 . • Do not panic. View it as a learning task in which incremental growth is necessary, and resist the thought, “I have to become an expert now. ” There are skills that you will need for the launch date of an online course, but there are many more skills that you will gain as the course progresses. It is not necessary to have expert knowledge in the full operation and maintenance of the LMS on the day that the course begins. In many ways, the situation is similar to that of a 88 6 Online Learning novice nursing student, who has engaged in learning so that she/he can safely provide the basic needs of a patient with predictable health outcomes. The student lacks the knowledge, skill, and experience to provide care for a patient whose health may be unstable, or who requires expert-level assessments and interventions. However, the fact that the student lacks the ability to provide sophisticated interventions does not negate the fact that he or she is prepared and able to meet some patients’ basic needs. Starting to teaching online in a new LMS brings an instructor back to this rudimentary position—able to provide the basics, and poised to grow. For Kyle, he needs to frame his learning in the priority need to become adept, but not an expert. • Try to view the LMS as a solution, rather than a problem It is important that Kyle view the LMS as something that has the long-term potential to actually increase his effi ciency and even reduce his workload. He needs to try to see it as a short-term challenge, and not as a threat. As evidenced by the fact that he has been hired to teach students who are paying money for his instruction, he is in possession of a long track record of wrestling with new knowledge and skills, and winning. Avoid worst-case thinking that serves only to heighten anxiety. In his clinical experience, Kyle has likely seen patients who have faced formidable health challenges with an upbeat, solution-oriented approach. The benefi ts of such an approach on both mental health and productivity are well-known. Before embarking on the challenge of mastering a new LMS (and during the process), Kyle will need to apply his skills of metacognition (thinking about his thinking) to foster a solution-oriented approach (Table 6.2 ). • Seek close collaboration with the institution’s educational technology (ET) staff. Ideally, one particular ally In some institutions, the technology side of the LMS may be separate from the department that is responsible for teaching and learning. In other institutions, these jurisdictions overlap and form a single entity. Regardless of the way that these services are organized, the fact remains that they exist in every institution in some form. A useful strategy for Kyle to adopt is fi nd out early what department in his college is responsible for the maintenance of the LMS and for orienting new users. This department will be independent of the nursing department, but is certain to be accessible to Kyle. We recommend a two-step process of engagement with the ET department. 1. Identify the Web-based and print resources on using the LMS that are hosted by the ET department. Some of these are likely to be available on the institution’s intranet or within the LMS itself. Others may be available from the website of the LMS vendor and hosted on video-sharing websites. Regardless of their location, these are a useful starting point for building a working knowledge of the LMS. As well, they lay a foundation for future interactions with an “ET ally.” 2. Make contact with an individual in the ET department and obtain that person’s direct contact information, if possible. In larger institutions, the ET department is likely to have multiple staff members, but Kyle will have much more success Instructors’ Perceptions of Feeling Unprepared 89

Table 6.2 Problem-oriented and solution-oriented perspective s Problem-oriented perspective Solution-oriented perspective This software is a mystery to me I’m not familiar with this now, but I will be Learning this is going to be so much This software is going to save me a lot of work in the work long run Students are going to know that I’m an I’ll learn what I need to know, by the time I need to amateur know it This is different than all of the software I’ve learned lots of new software in the past I used on a daily basis I’m not going to be ready by the course I’ve learned new software in the past … and it hasn’t start date always taken too long I feel out of control When I’m familiar with the LMS I’ll feel organized and in control I don’t even know what I don’t know I’m going to combine my intellect and help from others to learn what I don’t know

in getting the help he needs if he has consistent contact with a single individual (continuity of care, as it were) rather than piecemeal contact via the switchboard. In our experience, the people who are employed in ET and who actively maintain and make decisions about the LMS are almost always passionate and enthusiastic mavens. If you approach them from a position of sharing their interest in the technology they are typically happy to help. This process of collaborating with an ET ally is tantamount to forming a therapeutic partnership with a client or patient. As an experienced nurse, Kyle possesses the knowledge, skills, and attitude to establish rapport with diverse individuals. The application of these skills during interactions with an ET ally is fundamentally similar, allowing Kyle to apply Knowles’ ( 1980) conceptualization of experience within the practice of andragogy; he will ideally be able to apply his professional experiences and life experiences to this present learning situation. Chickering and Gamson (1991 ) emphasize the importance of contact between teachers and adult learners, and in this situation Kyle is the “student” while the ET ally is the teacher. An important caveat to collaborating with an ET ally, however, is that Kyle does not waste that person’s time by asking for help with a learning need that is already addressed elsewhere. The ET ally is more likely to engage with Kyle’s learning needs if he is not asking them to reiterate what’s already available in tutorials, online videos, archived webinars, handbooks, guides, or manuals. For example, if the ET department has posted a tutorial that walks instructors through the basic steps of setting up online groups, the consultant is probably going to be frustrated if Kyle phones asking for him or her to help him get started with setting up groups! The goal is to promote partnership so that the ET person sees you as an ally who has learning needs but who shares their interests, not a problematic user who asks him or her to solve problems that are easily addressed in material that the department has already made available. • Focus on the essentials 90 6 Online Learning

All the LMSs available in the current marketplace offer a dazzling array of functionalities. Because of this, it is necessary for Kyle to separate the essential functionalities from the less common and/or more complex ones. Some of these specialized functionalities meet the speciﬁ c needs of instructors while some, it could be argued, exist solely to differentiate the LMS from its competitors in the marketplace. In this early stage of the learning process, it is important for Kyle to focus on the “need to know” and set aside the “nice to know.” This is not unlike the approach that most instructors take with the software used for word processing, presentations and spreadsheets: the programs are capable of a staggering array of tasks, but the things that an instructor needs to be able to perform within that program are a small percentage. What tasks and competencies constitute “need to know”? (Table 6.3). It is common for there to be discrepancies between what a new instructor sees as being the “need to know” and what the ET consultant sees. An individual whose career is in information technology and educational technology often gravitates towards newly added or innovative functionalities. It is highly likely that some of the more arcane functionalities of the LMS are not a necessary focus for an instructor who is brand new to the online area. It is important for Kyle to trust an ET ally, but at the same time to engage critically with that person’s priorities. • Seek “reviewer” access to a variety of existing online courses All departments of nursing are subject to policies that require them to maintain paper-based student materials for a designated time period. In most cases, these policies also apply to online learning materials. This requirement creates a valuable resource for Kyle’s learning, because the educational technology department will possess archived copies of courses offered in the institution. Reviewing these archived courses is a valuable learning exercises and allows Kyle to enact the practice of active learning (Chickering & Gamson, 1991 ) in meeting his own learning needs. Regardless of which LMS Kyle’s institution uses, it has the ability to grant access to existing or completed course offerings. Of course, this requires that a designated individual grant electronic access, within the parameters of the institu-

Table 6.3 Entry-level skills • Posting content to the course for online teaching • Navigating the course content • Creating and posting news items • Navigating and editing the gradebook • Engaging in discussions • Setting up groups • Setting up quizzes, examinations, and other evaluative components • Recording and uploading audio • Recording and uploading video Instructors’ Perceptions of Feeling Unprepared 91 tion’s policies around privacy and confi dentiality. Being added to a course as a reviewer or observer, an instructor becomes privy to students’ discussion postings, assignments, grades and other submissions. Having the ability to scan one or more actual course offerings, in the institution’s LMS, provides a useful frame of reference for what a course looks and feels like. Kyle can read an instructor’s actual interactions with students and view the overall framework of the course. • View archived offerings of the same course you are teaching Even more valuable than reviewing other nursing courses is having a chance to examine archived offerings of the same course that you will be teaching. This allows Kyle to take his active learning (Chickering & Gamson, 1991 ) to an even higher level. If the course is new or being offered online for the fi rst time, then this is an obvious impossibility. Otherwise, go through the course as you would envision a student doing so. Begin with the syllabus or course outline, proceed to the course information guide or course overview, and then delve into the course content, starting from the beginning. Read the instructions for the fi rst discussion posting and then read what students have actually had to say in response. While doing so, make notes of what appears to work well, what is unclear and what improvements you can envision. If Kyle is able to do this, he will be simultaneously learning and doing quality improvement. • Use the “sandbox” in order to practice skills in a consequence-free environment Most LMSs provide an opportunity for you to enact the principles of constructivism and to learn by doing. In a “sandbox” or mock/shell course, there is an opportunity for Kyle to practice the precise tasks that he will be performing once his own course begins. This practice transcends active learning (Chickering & Gamson, 1991) and becomes what Knowles (1980 ) characterizes as orientation to learn. That is, Kyle can use acquired knowledge to solve problems through the application of his knowledge. He can practice posting a news item, deleting a course fi le and then uploading and replacing it with a different fi le, creating a link to content on the Internet, reconfi guring the student groups or editing a quiz question. This is similar to the vital role of simulation in nursing education , in the sense that it provides a realistic venue for applying knowledge, skills, and attitudes in a context where negative consequences can be minimized. While doing this, track which tasks go well and which do not. Follow this up with specifi c remedial learning using online resources or by consulting with your ET ally, thus maximizing time on task (Chickering & Gamson, 1991 ). • Remind yourself that you have expertise in the substance of the course, if not the style. Resist the temptation to buy into imposter syndrome with regard to the course content. As Kyle is learning the LMS, it is important that he remind himself that he is a competent and qualifi ed professional who knows the course content and possesses valuable experience (Knowles, 1980 ). It is important not to confl ate unfamiliarity with the method of course delivery with unfamiliarity with the course content. The former is simply a means to an end; the end, of course, is student mastery of the content, of which Kyle is an expert. 92 6 Online Learning

• Remember that you will almost always have time to sort out challenges asynchronously. It may take a long time to complete a technological task, but in most cases students will not be privy to your struggles. It is inevitable that Kyle will experience problems during the delivery of the course. However, one of the beneﬁ ts of asynchronous content in online courses is that students do not have to witness these struggles. Even if it takes Kyle several hours and multiple attempts to set up the course’s gradebook or create an online rubric, students will not be aware of this. For the novice online instructor, the delivery method is exceptionally forgiving or challenges and even errors, unlike teaching face-to-face, in a laboratory or in the clinical setting. In summary, there are many practices and changes in thinking that Kyle can use to enhance his mastery of online education. Applying these pragmatic strategies will maximize Kyle’s chances of being adequately prepared to use his institution’s LMS by the day that the course begins.

Scenario Two: Preventing a Lack of Engagement

Kyle vividly recalls some of the courses that he has taken online, in which there were always a few students who just seemed to be perpetually “absent” from the course. He states, “We were divided into discussion groups and there was a grade attached to our participation in the forums. In one group, I remember how two of the students never actually posted anything of substance. Some weeks, they’d post nothing, and in the weeks that they did post, it was just something like ‘great post Kyle!’.” I could tell that the instructor built in case studies and activities that were intended to get us thinking and interacting, but these students were basically ‘ghosts in the machine.’” Key Issue: Kyle needs to promote students’ genuine engagement with the course content, other students, and himself. The same fl exibility that makes online education attractive to students also con- stitutes a potential threat to its success. The fact that students can access the course at any time and any place also makes it possible for students to disengage with the course content. However there are a number of proactive strategies that an instructor can put into place to promote engagement and reactive strategies that can be used to promptly identify and address disengagement. • Link tightly to practice Students are more likely to invest their time and energy in course material if they perceive it as being authentic, interesting and relevant to their practice (Chickering & Gamson, 1991 ; Knowles, 1980 ). In the course design process, it is important to link course material to case studies that are either genuine events or, if they are con- trived, have an air of realism around them. For example, in a pharmacology course, ensure that there are direct and authentic links between the drugs being addressed Instructors’ Perceptions of Feeling Unprepared 93 and a client who would actually be taking those drugs. In a course on leadership and management, situate the theories that are being explored into a situation that has actually, or would plausibly, occur in a practice setting. Doing so is consistent with constructivism by allowing students to create meaning within the context of experiences, either vicariously or personally. In Kyle’s case, he is not creating a new course but is rather inheriting an existing course. He may lack the time and technical expertise to create new learning activities and embed them into the course. In all LMSs, however, it is possible to post material to the home page of the course, often as a news item. These news items can be useful supplements to the core course material, and can give valuable context to the material. Kyle could post this material himself or even elicit it from students, placing a callout for a situation in a hospital or community setting in which medications from a particular classifi cation were signifi cant, or where the leadership and management principles could be applied. Depending on students’ expertise, experience and the course material, this can be done before, during, or after the material appears in the course. This link to practice is one of aspects of online nursing education that gives it the potential to be three-dimensional, textured and affective. • Tell your stories Students are interested in instructors’ stories, and instructors like Kyle can lever- age this fact in order to promote engagement and prevent disengagement. Instructors each possess a large and varied body of interactions with patients, families, and colleagues. Students are investing time, money, and energy to build up their own body of interactions and are often captivated by the experiences of seasoned practitioners, especially experiences that took place while the instructor was a recent graduate. Not only does this situate content in an authentic context, but it has the potential to create rapport that transcends electronic distance. At the same time, Kyle must be careful of grandstanding or describing experiences solely for their shock value. Rather, he has to select experiences that provide a genuine framework in which to place the course learning activities and outcomes. • Respond to what students have to say Discussion postings are a nearly ubiquitous component of online learning. They provide a ready opportunity to engage students and have the potential to foster the reciprocity and cooperation desired by adult learners (Chickering & Gamson, 1991 ). In most courses, participation in discussions is mandatory and is most often graded according to a rubric that appraises the quality and quantity of a student’s contributions. Of course, making discussion postings mandatory and attaching grades to them will motivate most students to participate. However, participation at a level suffi cient to meet the criteria of a rubric is not synonymous with engagement. Kyle described how some of the students in his courses made token postings that did not refl ect full engagement. One way to combat this is by assuring students that what they post will be read by the instructor, and the only way to truly demonstrate to students that their postings are being read is to respond to them. This is no easy task 94 6 Online Learning for an instructor, especially in a course that may have many dozens of participants. However, it is imperative, since students are likely to mimic the instructor’s level of engagement with their own level of engagement. If students receive responses to their contributions, either personally or within the discussion forum, they are more likely to produce thoughtful and engaging posts. This is not to say that the instructor needs to match the quantity of a student’s contributions—doing so would be beyond onerous. It is possible to communicate that a student’s posting has been read and considered with a one or two sentence response. Neither should the instructor feel a need to respond to every posting in a discussion thread. Often a posting that summarizes or acknowledges the overall theme of a discussion thread is suffi cient to engage each of the students who contributed to the thread. Of course, responses from the instructor are meaningless unless they are actually read by the students. For that reason, if the instructor is going to respond in-line to the discussion, this needs to be done well in advance of the date that the forum closes. Few students are likely to revisit a discussion after its end date. If it is not possible to respond while a discussion is still open, the instructor needs to use the functionalities of the LMS to ensure that his or her posting is forwarded, or at least fl agged, for the student participants. • Build in synchronous activities at regular intervals The structure of online courses includes varying amounts of synchronous and asynchronous content . Synchronous content is presented in “real time” and can take the form of a narrated presentation or video conference. The technology for such content is usually embedded in the LMS, though it may also be possible, or even necessary, to use external software. Regardless of the means, presenting synchronous content puts the onus on students to be logged in and present in the course, at a particular time. This content may or may not be archived for later access by students; if it is not archived (and if this is announced well in advance), this creates an even more powerful incentive for engagement, albeit in the short term. Synchronous activities can be daunting for a new instructor such Kyle, in whi ch the medium seems to overshadow the message. Synchronous content does not necessarily have to consist of a 60-min presentation, however. A 10-min “catch-up” at the beginning of the week can suffi ce, provided it accommodates students’ busy schedules. As well, Kyle could schedule a synchronous session to address some of the most interesting or nuanced discussion postings during the previous module. • Vary your voice Students are most likely to be engaged if you vary your interactions with them. For example, if you post a video summary of the previous week’s highlights, follow that the next week by posting a link to a relevant newspaper item or journal article. Utilize the functions of the LMS to their fullest, posting audio clips, hyperlinks, video and PowerPoint presentation. The students should not “see” you in exactly the same way every time. If these postings are not directly linked to students’ submissions, it is possible to create them before the course begins, or at any other opportune time, and to schedule them for future release by the LMS. Instructors’ Perceptions of Feeling Unprepared 95

• Personalize your contact with students LMSs can be set to send updates to students in which their name is automatically substituted into a specifi ed fi eld. Utilizing this function generates person-to-person contact between the instructor and student, drawing in the student and making it more diffi cult for the student to disengage. This is an effective way of reconciling your own workload with the need to promote contact between adult students and faculty (Chickering & Gamson, 1991 ). • Invite guests Guests in an online course? Yes, it is certainly possible. A clinical expert, recent graduate, patient, or another faculty member can be enlisted to participate in various ways. The guest could be asked to contribute to online discussion or to post a video or audio recording to the course home page. A powerful technique for highlighting the relevance of course content is to have a nurse write or record a testimonial, a narrative or an editorial that explores the link between the course objectives and the guest’s real-life practice. Another popular alternative is to have the guest hold a synchronous “ask me anything” (“AMA”) session in which students can pose questions to the guest and have them answered in real time. • Set fi lters and access restrictions The LMS allows you to set access restrictions that control the release of content. These can be used to incentive engagement. For example, the instructor can easily make the completion of a brief summary quiz a precondition for the student’s access to the subsequent module. Students are certainly capable of creating “workarounds” for many of these restrictions, but they nonetheless have the potential to create engagement. Course content can be hidden from students until they have submitted a review activity to the drop box or completed a survey. Alternatively, date restrictions can be placed on material that encourage students to keep pace with the progress of the course. LMS settings can also be created to require a student to contact the instructor if he or she has not logged into the course for a particular length of time or has not completed a particular learning activity. Regardless of the strategy, an ET ally is likely to be of assistance in creating the necessary settings. • Make early contact with students who are disengaged One of the benefi ts of an LMS is that it allows the instructor to gauge every student’s electronic interactions with the course. For example, in Desire2Learn’s “Student Progress” fi eld, the instructor can view every student’s progress in numerous domains: • Number of times visiting the course • Last login • Number of discussions read, created, and replied to • Number of quizzes completed • Quiz grades • Drop box submissions • Surveys completed 96 6 Online Learning

• Pages visited • Total number of course log-ins • Time spent logged in (Fig. 6.1 ) If it were necessary for the instructor to manually monitor these indicators, gauging student progress would be an overwhelming task. However, the LMS can be set to generate contact with the student, and to notify the instructor, if a student’s absence from course progress exceeds deﬁ ned parameters. This makes it much easier for the instructor to know who is lagging behind and to make contact and can usually be set up with the assistance of an ET ally at the beginning of the course. Making direct contact with students who are disengaged, or who appear to be, is imperative. The instructor can make contact by various means, but contact by means apart from the course may carry more weight. For example, phoning a student to check up may provide a more powerful incentive to engage than sending an e-mail or intra-LMS message, which can easily be ignored. In summary, there are practical actions that can be taken to create engagement in the online domain, ensuring that geographical distance does not result in interpersonal distance.

Scenario Three: Promoting Community

When Kyle thinks about the online courses that he took during his masters degree, there were times when he felt disconnected, not from the course content, but from his fellow students. He states, “Nursing is inherently interpersonal and affective. It’s not just about presenting and comprehending material and I ﬁ rmly believe that the learning experience should align with this. Learning should take place in a community, not only because of students’ needs for mutual support but because that’s what nursing is.” Online learning in nursing must promote engagement, but at the same time it should transcend just authentic participation and result in community. Creating community is simultaneously one of the most important and challenging aspects of online education. Impersonality, lack of relationships and isolation have been cited among the major challenges of online learning since its inception (Attack & Rankin, 2002 ; Lloyd et al. 2012 ; Olson & Benham-Hutchins, 2014 ). A sense of community enhances motivation, engagement and performance (Lahaie, 2007 ). Key Issue : Kyle needs to promote a sense of community in order to enhance the teaching-learning proces s. Chickering and Gamson (1991 ) highlight the importance of not only contact between students and faculty but also collaboration and cooperation among students—practices that are consistent with the development of community. It requires deliberate and thoughtful action to foster community in the online domain, but it is possible. Students who experience a sense of community in an online course are more likely to engage deeply with the learning experience and have higher rates of retention, self-esteem and perceived competence (Leners & Instructors’ Perceptions of Feeling Unprepared 97

Fig. 6.1 Individual student progress in Desire2Learn ( D2L )

Sitzman, 2006 ). There are strategies that Kyle can apply in order to create and promote and sense of communit y. • Demonstrate that you care about your students Online students have expressed a need to know that their instructors care about them (Mastel-Smith et al., 2015 ). The importance of caring has been shown to such a high degree that it is likely safe to say that authentic online community cannot develop in the absence of the instructor’s caring. Research has identifi ed numerous strategies and practices that instructors can implement in order to demonstrate caring (Mann, 2014 ; Plante & Asselin, 2014 ; Sitzman, 2010 ): • Exemplify “netiquette” All of the online instructor’s communications—course content, e-mails, news postings, discussions, and assignment feedback—should demonstrate the basic, civilized social conventions of online communication. Characteristics of netiquette 98 6 Online Learning include writing clearly, succinctly and on-topic. As well, communication should be tactful, respectful, polite, and use correct spelling and grammar. Maintaining a respectful tone and refraining from sarcasm are essential, as is the judicious use of humor, which can easily be misinterpreted in the online sphere. • Follow through on your promises If you promise to post to the discussion forum mid-week, do so. If you state that you will post links to interesting news articles over the course of the term, do so. If you promise to post a study guide 1 week in advance of an examination, do so. In order to promote caring it is necessary to adhere to the ethical principle of fi delity. The importance of fi delity in establishing therapeutic nurse-patient relationship is well-known; it is equally important in establishing therapeutic and productive learning communitie s. • Be consistent in your accessibility At the outset of the course, it is imperative to communicate to students when you will be available for real-time consultation (offi ce hours) and what kind of turn- around time they can expect to e-mails or postings to a student questions forum. A maximum of 48 h is suggested. Students identify prompt responses to their queries as a signifi cant indicator of caring. As well, be clear to students on which days you will not be engaging with the course (weekends? only Sundays?) and ensure that you stick to this schedule. Be wary of engaging with the course or with individual students on days when you have stated that you will be inaccessible. Doing so may feel like going above and beyond for students, but it serves to nullify the parameters that have set, ultimately sowing confusion. Additionally, it creates an expectation for other students and for future communications. When planning learning activities and choosing due dates, ensure that they are unlikely to require your input on days when you will not be accessible. • Give clear instructions The principle applies not only when providing instructions for completing assignments or learning activities, but also for stating how to navigate through the course, how to complete discussion postings. It is helpful to have a colleague review guidelines and instructions to identify any inconsistencies or assumptions. This may seem to be a purely pragmatic consideration, but its application enhances the sense of caring and community, not solely the logistical operations of the course. • Demonstrate empathy In almost all cases, students will be participating in other courses simultaneous to your online course. Instructors need to remind themselves frequently that students are busy people with competing priorities and multiple responsibilities. Students perceive their instructor as caring when he or she acknowledges this reality and makes reasonable efforts to refl ect it when determining workload, scheduling and due dates. Whenever possible, collaborate with the instructors of other courses that students will be taking simultaneously to plan due dates that are reasonably Instructors’ Perceptions of Feeling Unprepared 99 spread out rather than clustered. In nursing, course scheduling should also consider students’ clinical schedules. In an era of increased competition for clinical time, it is ideal to avoid making major assignments due, say, the day after students have completed a series of 12-h shifts. • Make yourself known; be selectively vulnerable Nursing students benefi t when instructors are willing to describe authentic clinical and education experiences and when they reveal their humanity, going beyond a purely technical role. Maintenance of professional boundaries is imperative, of course, in the same way that boundaries exist during interactions between a nurse and a client or family. At the same time, telling your own stories can communicate that you empathize with their own learning situations, having had similar experiences yourself. Creating a thoughtful introductory or biographical posting is an opportune time to set this tone. Consider recording a video biography and selectively reveal some parts of your life and interests that transcend nursing education. • Elicit students’ feedback and act on it Build opportunities into the course for students to give formative feedback on the structure and content of the course, ideally near the midpoint of the course (Chao et al., 2006 ). This builds community by demonstrating a tangible commitment to the quality of students’ learning experiences. This can be done in varied ways: a survey, a questionnaire or simply an invitation for e-mail communication. Acknowledge such feedback in a summary statement and indicate what course changes it will inform. Most importantly, follow through on these changes. • Keep the course organized using the calendar In a course that involves discussion postings, quizzes, assignments and examinations there can potentially be dozens of major and minor deadlines and due dates. Multiple this by the number of courses that a student may be taking and it creates the potential for a fragmented and confusing schedule. Fortunately, all LMSs have the ability for the instructor to create an online calendar denoting due dates for learning activities and examination dates. The advantage of using the LMS calendar rather than providing a document-based schedule is that the student can collate his or her calendars from multiple courses into one master calendar. • Give feedback promptly Students perceive their instructor as caring when they receive timely feedback to their contributions, whether they be discussion postings or formal assignments . In cases where it is not possible to give feedback promptly, inform students of this clearly and explain the reason. • Foster social presence In the absence of nonverbal communication and physical presence, the instructor needs to be deliberate in his or her efforts to establish and maintain social presence . Some of the strategies that have been shown successful include posting a 100 6 Online Learning photograph in the form of an avatar that accompanies all of your communications and encouraging students to do the same. The use of congenial greetings and expressing positive reinforcement have been shown to foster social presence (Cobb, 2011). While it is important to be practical and succinct in your communications, do not be solely bound to the course content or the tasks associated with it such that your communication is blunt and simply pragmatic. Take the time and effort to exemplify some of the pleasantries that distinguish a well-written letter from a text message, especially in communications that will be read by many or all of the students in the course. Both styles of writing convey a message, but the former frames the communication in the “humanness” that promotes community (Lahaie, 2007 ). This is not to say that communications must be characterized by the formality of a letter, but rather the decency. It can be tempting to use the conventions from text messaging that substitute for nonverbals (emojis, emoticons, and abbreviations such as “ROTFL”), but in most cases these are inconsistent with creating a tone that is thoughtful and empathic yet scholarly and professional. • Invite guests, especially those with a story to tell In the same way that inviting guests promotes student engagement with course content, it can also have a powerful affective infl uence on the course community. This is especially the case when the guest is not a nurse but a person who is living with illness or disability or who is a caregiver for such a person (Bristol and Zerwekh, 2011 ). The shared experience of engaging with individuals who are the true focus of nursing care is a powerful builder of community among learners. • Build learner-to-learner interaction into the learning activities Two of the examples of where student interaction is built into a course are discussion forums and group assignments. Both provide opportunities as well as threats to the creation of community. Discussion forums must be suffi cient in quantity and frequency that students can generate momentum and familiarity in their interactions. At the same time, the expectations must not be so high (i.e., the number of discussions or the quantity of required postings) that they simply become a task for students to cross off their weekly lists. Discussion forums that promote community ask questions that are specifi c yet open-ended, in which there is a clear line of sight between the discussion topic, the course content and nursing practice. They should take place in groups that are neither too small nor too large. A minimum of four students is needed to provide a diversity of input; a maximum of around eight students ensures that no student can wholly disappear. Group assignments must similarly be organized so that the process of completing the activity promotes community rather than frustration. An important element of this is ensuring that the learning activity is something that would be authentically completed by more than one nurse. For example, something like a nursing care plan is always a collaborative effort; a refl ective essay about the signifi cance of a client interaction is not. As in all settings, group assignments in online education must be premised on the need for authentic interaction and collaboration, not the instructor’s need for less marking. Instructors’ Perceptions of Feeling Unprepared 101

• Make it easy for students to ask questions Every course should have a designated location, usually a discussion forum, where students can post questions about course operations, assignments, expectations, and content. Usually entitled something like “Student Questions,” the instructor should monitor this forum closely and post responses promptly. Make it clear that the instructor is not the only person who can post responses. Very often students will know the answers to each other’s questions and should be encouraged to answer them. If this happens, post a quick note of thanks in order to demonstrate civility and to promote similar responses in the future. Many instructors also create a student discussion forum that is not focused on course progress or content, but is rather a place for students to debrief, seek advice from each other or exchange information. Often this is titled a “student cafe” or something similar. Inform students that you will not be monitoring this forum so that they feel free to make postings without instructor oversight. At the same time, it is best to inform them that conﬁ dentiality is not guaranteed and that they should be careful to avoid making postings that they would not feel comfortable discussing in a physical, on-campus setting. • Encourage and facilitate students’ use of varied communication medi a In much the same way that course engagement is enhanced by the instructor’s use of varied communication media, students should also be encouraged to supplement their typed contributions with audio and video. Most students already possess the skills and the technological capabilities for doing so. Encouraging students to summarize a salient component of the course content in a brief video “Vine” is an innovative and engaging activity that builds community. Such an activity could be followed up by a survey to recognize the best quality contributions. Even in the absence of fact-to-face contact, it is possible to foster community among students and instructors who are interacting online. Applying these strategies will allow Kyle to demonstrate that he cares about his students, which is essential to this development of community.

Scenario Four: How Can I Prevent Academic Dishonesty ?

Kyle recalls that when he was taking an online course, there were persistent rumors that a small group of students were colluding to write their online examinations in a group. The exams were ostensibly closed book, and there was a requirement to use a “lockdown browser” that permitted only the window that contained the exam to be open. “The problem,” he states, “is that you could write them anywhere you wanted and there was no barrier at all to having another computer or device on your desk, making the entire Internet available to you during the exam. He also says that the exam was available from 0600 to 1800 in order to accommodate students’ varied schedules. “It was considerate of the instructor, but the way the exams were 102 6 Online Learning set up seemed to reward students who were dishonest and punish those who followed the rules. It made the testing a bit of a sham, and I don’t want to be associated with anything like that when I’m the instructor.” Key Issue : Kyle needs to take action to prevent cheating and identify it quickly when it occurs. It is widely accepted that academic dishonesty is a major challenge in the delivery of online education, and that the online domain both provides more opportunities for dishonesty and makes it harder to address (Hart & Morgan, 2009 ; Johnson, 2006; Krsak, 2007). As Kyle gains familiarity with the LMS and within online teaching practice, there are several practices that he can put in place that will make academic dishonesty more diffi cult, less attractive, and easier to detect. • Expect and promote honesty Any plan of action to address academic dishonesty should begin from the premise that the instructor highly values honesty, expects honesty and exemplifi es honesty. Establishing an “atmosphere of integrity” (Hart & Morgan, 2009 ) begins with such simple actions as ensuring that course components from outside sources are credited appropriately and that hyperlinks connect to resources that are explicitly within the public domain. Many institutions require students to view and agree with an academic honesty policy at the outset of a course. It is well-known, however, that clicking a box that says “I agree” is not necessarily a powerful or binding commitment. At the British Columbia Institute of Technology, students’ access to any of the course content is restricted until they have completed a brief online module that provides information about academic honesty, specifi es the consequences of dishonesty, tests the student’s knowledge of the topic through brief checkpoint quizzes and culmi- nates with a signed pledge of academic honesty. The principles of academic honesty are linked throughout the module to the provincial Standards of Nursing Practice and the general principles of nursing ethics. Student feedback has stated that this is perceived as being more robust and binding than simply reading and agreeing with a policy. Chickering and Gamson (1991 ) emphasize the need to communicate high expectations to adult learners. This principle can be applied not only to academic work but also to the way in which students carry themselves ethically. • Hold examinations in a proctored environment whenever possible Many of the opportunities for academic dishonesty are mitigated when students are required to be present on campus to write an examination, whether it be paper- based or electronic. Of course, this runs somewhat contrary to the premises of online education, but depending on the characteristics of the student cohort and the placement of the course in the overall nursing program, it may be possible. An alternative is to use a proctored test that students must complete in a controlled environment. There are numerous sites that allow students to complete an examination in their controlled environment. Options include for-profi t test-writing centers, libraries, colleges and public schools. This requires a signifi cant amount of organization, and possibly cost, by students and instructors, so it is best reserved for summative examinations. Instructors’ Perceptions of Feeling Unprepared 103

Online examinations where students write at any site of their choosing adheres closely to the principles of online education. However, this creates ample opportunities for dishonesty, including collusion by pairs or groups of students, students having others impersonate them and students making copies of examination materials using screenshots. If there is no alternative but to have students write off-site, several actions are necessary: • Use multiple choice examinations with caution Multiple choice questions, such as those that predominate in the NCLEX, are a nearly ubiquitous feature of nursing courses. In the online domain, the use of multiple choice questions presents challenges. The instructor must presume that the examination is open-book, and should designate it as such as not to put the more honesty students at a disadvantage. Multiple choice exams that exist at low levels on Bloom’s taxonomy of cognitive learning can become just a hunt for the correct answer; multiple choice questions at the application and analysis level make it more diffi cult for students to simply look up the answers. It is unnecessary to avoid all forms of multiple choice examinations in the online setting, but it is necessary to ensure that they are suffi ciently high on Bloom’s taxonomy to make it more diffi cult to collude. • Set a realistic, but tight, time limit Security and integrity are enhanced when there is reasonable balance between allowing enough time to clearly demonstrate content mastery while not granting enough time for real-time research that compensates for a lack of knowledge. There is no fi rm agreement in the literature about the ideal length of time for each multiple choice question. There are a number of variables that must be considered when choosing a time limit, including the length of the stems, the complexity of the questions, the length of the key and distractors, the number of distractors, the cognitive level of the questions and the use of multi-select questions, In the authors’ experiences, approximately 75 s per multiple choice question is appropriate with adjust- ments made in light of these variables. • Offer the exam synchronously Even if the majority of course content is offered asynchronously, exams should be conducted synchronously. Doing so may present some scheduling challenges , but it reduces the opportunities for students to communicate examination materials to students who have not yet written. • Offer each student a different exam This is best achieved by: (a) having a large bank of questions to draw from; and (b) randomizing each students’ selection of questions. Of course, this presumes an ample number of questions from which to draw, something that takes time and energy to create. If importing questions from the test bank of a textbook it is benefi - cial to review and lightly edit them to counteract any student’s contact with the test bank. When creating your own test bank, aim to have at least three times more questions than will be offered to a student. 104 6 Online Learning

• Create questions that prioritize analysis, application and the student’s own experiences. It is more difﬁ cult for a student to rely on outside sources if he or she is required to apply the course material and integrate his or her own experiences. Note as well that these types of short- and long-answer questions may also be randomized in the same way as multiple choice questions. • After exams are complete, review some “event logs” in order to detect unusual patterns. LMSs allow you to view when a student logged into exam, answered a question, saved work, and logged out. Unusual patterns such as entering several answers in rapid succession or logging in and out repeatedly may suggest inappropriate conduct. It is impractical to review every student’s event log, but some instructors inform the class in advance that a number of exam logs will be reviewed (Fig. 6.2 ). Assignments also present challenges to academic honesty, though the challenges differ from those of examinations. Some of the practices that deter or detect plagiarism include the following. • Examine the metadata of documents that you suspect Written assignments are most often submitted in Microsoft Word (.doc or .docx) format. Many students do not realize that Word documents include a wealth of information about the document, readily available to a reader under File → Info. These metadata include the identity of authors and editors, the time the document was last edited, the time spent editing the document, and the existence of previous versions of the document. The “Document Inspector” functionality in this pane allows for even more detailed inspection. A review of these metadata can sometimes corroborate suspicions about the integrity of a student’s work. For example, if a previous student is listed as one of the “Related People” in a document, it raises the possibility of academic dishonesty (Fig. 6.3 ). • If co-teaching, randomize who marks which student’s assignment Previous students of a course are aware of who marked their assignments. In light of this, there can be a temptation toward plagiarism if a current student knows that a different instructor will be marking his or her assignment. A strategy for preventing this is to remove students’ certainty around who will mark their assignments. • Make minor changes in the expectations or content of assignments Making minor changes to the format or content of an assignment make it easier for the instructor to identify if a student has appropriated content from a previous course offering. For example, mandating the use of headings and subheadings could be added in, or the wording of headings slightly altered. A similar strategy involves the use of forms or worksheets. Even if these are substantively similar from term to term, minor changes in the content (or metadata) can make it easier for an instructor to identify unoriginal material. Instructors’ Perceptions of Feeling Unprepared 105

Fig. 6.2 Quiz event log in Desire2Learn (D2L)

Scenario Five: How Can I Stay Connected with My Department and My Colleagues When Teaching from a Distance?

Kyle has been surprised to learn that there are a handful of faculty members in the nursing department whose full teaching load consists of online courses. “Obviously, I knew that online education has been growing for many years,” he says, “but it never really occurred to me that there would be full-time nursing professors whose entire teaching load is electronic. I can see how an experienced nursing educator would be able to draw in clinical experiences to make the online experience authentic, but what happens if you’re not adding to that body of experiences? Not just from the clinical setting, but even interactions in the simulation lab, or face-to-face interactions with students in the classroom. Isn’t there are real risk of becoming obsolete and disconnected? Also, I’ve only just recently found out that there are these ‘faculty- at-a-distance’ people in the department. That tells me that they might not even be fully-integrated contributors to the culture of the department. I know that if that were me, I’d feel disconnected from not only individuals in the department, but also the overall spirit and buzz of the department. I know from my own experience 106 6 Online Learning

Fig. 6.3 Document metadata in Microsoft Word that every workplace has a defi nite culture, with its own norms, character and assumptions, and that this culture is constantly shifting. How can someone stay plugged into the culture of the department when all of your teaching is electronic and you might even live in another city?” Distance education in nursing is certainly not a new phenomenon. Indeed, some of the earliest educational offerings in the fi eld were delivered by the traditional correspondence course, in which the student and the instructor were geographically separated. A more recent development, however, is what Pearsall et al. ( 2012 ) call the faculty-at-a-distance nurse educator role. In this role, a nurse educator is physically located at a site distant from the institution and performs all of his or her instruction electronically. While this arrangement offers solutions to both educational institutions (fi lling vacancies that might otherwise be diffi cult to fi ll) and educators (geographic fl exibility), it also creates challenges that must be addressed. For the educator and the institution alike, it is important to establish and maintain a sense of connectedness, shared vision and collaboration. Whenever a nurse educator is located at site distant from the institution, there is a risk of isolation, and even unaccountability, Pearsall, Hodson-Carlton and Flowers note that in terms of the NLN Nurse Educator Competencies, educators at a distance fi nd it particularly challenging to facilitate student learner development and social function within the educational environment. Fortunately, there are strategies that a nursing educator who is distant from the institution can apply in response to this challenge. Instructors’ Perceptions of Feeling Unprepared 107

• Be deliberately interactive with your colleagues When a nursing educator is on the same physical site as the other members of the department, there is a great deal of incidental, piecemeal interaction that builds familiarity and, hopefully, trust. In the “cyber-context,” however, this is not the case; colleagues at the institution have no contact from the educator at a distance unless the educator deliberately communicates. In order to avoid becoming “invisible” in the department, it is important to be deliberate in the following ways: • Acknowledge receipt of e-mails, even if the content does not necessarily demand a response • Weigh in to departmental discussions that take place by e-mail. Even if the content is purely informational, offer a refl ection, a validation, or a follow-up point. • When appropriate, do not hesitate to use “reply all” in response to departmental e-mails. • Volunteer to take on departmental tasks that can be performed from a distance, and then communicate to the department your progress, challenges or results. • Disseminate interesting, timely or insightful articles to colleagues electronically It is important to note that these interactions are not intended to be disingenuous or manipulative. Rather, they are intended to address the reality that that there is no other opportunity for incidental interaction when the educator is at a distance. After all, when teaching from a distance, there is no opportunity to chat with colleagues in the lunchroom or while waiting for a department meeting to begin. The educator must apply many of the same skills as when teaching online, where contact with students must be deliberate, systematic, purposeful, and frequent. • Create accountabilit y Every school of nursing has a formal performance appraisal or professional development program, in which faculty members must document and demonstrate a commitment to growth and excellence. Most of these programs, however, are premised on the fact that in educators are in close, frequent collaboration. Working from a distance creates a risk for isolation, which can in turn create a risk for professional complacency. In traditional nursing education, the frequent interactions with colleagues create an implicit sense of accountability. This does not exist in the same way when the educator is at a distance, and for this reason, extra effort must be made to engage in producing and consuming scholarship. It may be useful to create a partnership with another nursing educator at a distance and affi rm a commitment to regular course reviews, scholarship and general best practices. This will not only enhance the quality of education, but will foster the educator’s connection with the larger department by protecting against isolation. • Go to the campus Regardless of how much distance exists between the educator and the institution, there is great benefi t from going to the campus from time to time. Clearly, there are 108 6 Online Learning many variables that affect how often, and for how long, the educator can do this. For some, this may be a matter of fi ghting traffi c for a couple of hours’ drive. For others it may involve a full day of air travel costing several hundred dollars. Regardless, there is often immeasurable benefi t in being physically present on campus from time to time. Ideally, this should be done at a time when there is maximum activity on campus. In many programs, this is likely to be near the beginning or a semester or at the end of a semester, when the educator can maximize interactions with colleagues and supervisors. In addition to the benefi ts of these individual interactions, travelling to the institution demonstrates a commitment to staying engaged and accountable within the program and shows that the educator does not want to be psychologically distant from the program. Even for educators whose teaching assignment are not 100 % online, and who live close to campus, this principle applies. In Kyle’s case, he lives in the same region as the school of nurse that hired him, but the same benefi ts of being present on campus apply. • Advocate for enhanced electronic communicatio n Pearsall et al. (2012 ) identify attending faculty meetings and contributing to committee and departmental work among the most signifi cant challenges to the faculty-at-a-distance role. Despite the fact that colleges and universities possess the technological infrastructure to offer nursing courses online, many still lack the necessary capacity for reliable and user-friendly video conferencing, or even telecon- ferencing. Often the capacity for these means of communications exists, but it poorly understood or irregularly available. In order for a nursing educator to be able to fulfi ll a full complement of academic responsibilities, the necessary technology must be both available and reliable. Nurse educators in all locations must advocate for these technologies and for the necessary technical support to ensure that they are available when needed. Teaching online does not have to be an isolated activity in which the educator exists parallel to the larger department, never intersecting. By maintaining thoughtful contact, creating accountability, visiting campus and advocating for the necessary technology, a nurse educator at a distance can remain an integral part of a school of nursing.

Conclusion

Online education provides unprecedented opportunities for contemporary nursing students and their instructors. At the same time, it presents unique challenges. These challenges are varied, but often include difﬁ culties with the LMS, challenges in engaging students and fostering community, as well as the ever present threat of academic dishonesty. However, there are strategies that any new instructor, such as Kyle, can employ in order to maximize his own comfort level and, ultimately, student learning. References 109

References

Allen IA, Seaman J. Grade change: Tracking online education in the United States. Babson Park, MA: Babson Survey Research Group and Quahog Research Group; 2014. Attack L, Rankin J. A descriptive study of registered nurses’ experiences with web-based learning. Journal of Advanced Nursing. 2002;40(4):457–65. Bristol T, Zerwekh J. Essential of e-learning for nurse educators. Philadelphia: F.A. Davis; 2011. Carlon S, Bennett-Woods D, Berg B, Claywell L, LeDuc K, Marcisz N, et al. The community of inquiry instrument: Validation and results in online health care disciplines. Computers & Education. 2012;59(2):215–21. Chao T, Saj T, Tessier F. Establish a quality review for online courses. Educause Quarterly. 2006;29(3):32–9. Chickering AW, Gamson ZF. Applying the seven principles for good practice in undergraduate education. San Francisco, CA: Jossey-Bass; 1991. Cobb SC. Social presence, satisfaction, and perceived learning of RN-to-BSN students in web- based nursing courses. Nursing Education Perspectives. 2011;32(2):115–9. Edutechnica. (2015). LMS data: Third annual update. Retrieved February 12, 2016, from: http:// edutechnica.com/2015/10/10/lms-data-3rd-annual-update/ . Hart L, Morgan L. Strategies for online test security. Nurse Educator. 2009;34(6):249–53. Illinois Online Network. (n.d.). Competencies for online instructors. Retrieved February 12, 2016, from: http://www.ion.uillinois.edu/institutes/presentations/030124/ION/Compentencies_ﬁ les/ frame.html . Johnson A. Faculty preparation for teaching online. In: Novotny J, Davis R, editors. Distance education in nursing. 2nd ed. New York: Springer; 2006. Knowles M. The modern practice of adult education. New York: Cambridge; 1980. Krsak, A. (2007). Curbing academic dishonesty in online courses. TCC 2007 Proceedings. Retrieved February 12, 2016, from etec.hawaii.edu/proceedings/2007/krsak.pdf. Lahaie U. Strategies for creating social presence online. Nurse Educator. 2007;32(3):100–1. Leners D, Sitzman K. Graduate student perceptions: Feeling the passion of caring online. Nursing Education Perspectives. 2006;27(6):315–9. Lloyd, S., Byrne, M., & McCoy, T. (2012). Faculty-perceived barriers of online education. Journal of Online Learning and Teaching, 8 (1). Mann J. A pilot study of RN-BSN completion students preferred instructor online classroom caring behaviors. Association of Black Nursing Faculty Journal. 2014;25(2):33–9. Mastel-Smith B, Post J, Lake P. Online teaching: “Are you there and do you care?”. Journal of Nursing Education. 2015;54(3):145–51. Mayne LA, Wu Q. Creating and measuring social presence in online graduate nursing courses. Nursing Education Perspectives. 2011;32(2):110–4. McAfooes J. In: Billings D, Halstead J, editors. Teaching in nursing: A guide for faculty. 5th ed. St. Louis: Elsevier; 2016. Morgan L, Hart L. Promoting academic integrity in an online RN-BSN program. Nursing Education Perspectives. 2013;34(4):240–3. Olson, C., & Benham-Hutchins, M. (2014). Learner presence in online nursing education. Online Journal of Nursing Informatics, 18 (3). Pearsall C, Hodson-Carlton K, Flowers J. Barriers and strategies toward the implementation of a full-time faculty-at-a-distance nurse educator role. Nursing Education Perspectives. 2012;33(6):399–405. Plante K, Asselin M. Best practices for creating social presence and caring behaviors online. Nursing Education Perspectives. 2014;35(4):219–23. Sitzman K. Student-preferred caring behaviors for online nursing education. Nursing Education Perspectives. 2010;31(3):171–8. 110 6 Online Learning

Szabo, M., & Flesher K. (2002). CMI theory and practice: Historical roots of learning management systems. In World Conference on E-Learning in Corporate, Government, Healthcare and Higher Education, Montreal, Canada. AACE. Watson W, Watson S. An argument for clarity: What are learning management systems, what are they not, and what should they become. TechTrends. 2007;51(2):28–34. Zsohar H, Smith J. Transition from the classroom to the Web: Successful strategies for teaching online. Nursing Education Perspectives. 2008;29(1):23–8. Appendix A: Example Course Syllabus

School Name School of Nursing Course Number and Name Semester ***Note: Each school typically has a determined template for the syllabus. This is provided in case there is not a predetermined syllabus. Course Credits: ___ hours Theory: ___ hours Clinical: ___ hours (__ contact hours) COURSE DESCRIPTION : COURSE OBJECTIVES : COURSE PREREQUISITES : FACULTY: REQUIRED TEXTBOOK RECOMMENDED READING TEACHING/LEARNING STRATEGIES: COURSE POLICIES Participation: Active participation (online and clinical) is required to be successful in this course. Communication: Students are responsible for full knowledge and compliance with all announcements posted on Moodle or presented in the classroom. Students are required to regularly check their College e-mail account and Moodle and are held accountable for its contents.

The School of Nursing is not responsible for information that is missed because the student fails to check his/her E-mail. Graduating students PLEASE monitor the College web site in order to stay informed concerning graduation/award ceremonies and responsibilities. Professional Behaviors Students are expected to conduct themselves in an ethical and a professional manner. Inability of the student to meet the expectations for student behavior may result in reduction of the fi nal course grade. If any of the expectations are consistently violated the student will not have successfully completed the course. Evidence of providing misleading information, cheating and/or falsifi cation of the spoken or written word (e.g., records) will be grounds for immediate dismissal from the School of Nursing. Specifi c guidelines for dismissal are outlined in the Nursing Student Handbook. Late Assignments: Assignments/Late Assignments: Written assignments are due on the designated date and time. The due dates for all assignments are identifi ed in Moodle. Students are responsible for submitting assignments (uploading to Moodle) on the date and time designated on the Course Calendar. Late assignments may be submitted up to 72 h past the assignment due date; however, a penalty of 10 % of the total points for the assignment will be deducted for each 24 h the assignment is past due. Assignments submitted later than 72 h will receive a zero. Written assignments must follow APA format, when indicated. Grades Allocation: Students must successfully pass classroom and clinical components to pass Nursing _____. A grade of 80 % is required to pass this course.

Checkpoints (20 points each) 40 points Community Action Plan 40 points Forums 20 points Total 100

Grading Scale: Undergraduate School of Nursing:

94–100 = A 80–83 = C 91–93 = B+ 78–79 = D+ 87–90 = B 75–77 = D 86–81 = C+ 0–74 = F Appendix B: Program Outcomes

BSN Degree Program Outcome Measures : 1. 90 % of the graduates will pass the NCLEX-RN licensure examination on the ﬁ rst attempt. 2. Within 1 year of graduation, employers will report that the graduates provide high quality, compassionate, and competent care. 3. Within 2 years, 85 % of the graduates will report involvement and participation in at least one professional organization.

Appendix C: Exam Blueprint

# # Exam Exam items items Date Time Room Event/lecture topic unit ﬁ nal Faculty Tuesday TBA Junior Level All Faculty 8/12/14 Orientation Wednesday 9–10 am Assigned Dosage and Faculty 8/13/14 10–11 pm room goes Calculation Exam who is 11–12 pm here Sr. Roy (1) 4 2 teaching 1–3 pm Legal (1) 4 2 content is listed here Perioperative (2) 8 4 Monday 1–5 pm And so on Respiratory (4) And And And so on 8/18/14 so on so on Monday 1–5 pm Diabetes (4) 8/25/14 Tuesday 8–9 am Exam I (11 h) All Faculty 9/2/14 Monday 1–5 pm Cardiovascular I (4) 9/8/14 Monday 1–3 pm Cardiovascular II (2) 9/15/14 3–4 pm Male Repro (1) Monday 1–5 pm Musculoskeletal (4) 9/22/14 Monday 11–12 Exam II (11 h) All Faculty 9/29/14 noon Monday 1–5 pm Neuro I (4) 9/29/14 Monday 1–3 pm Neuro II (2) 10/6/14 3–5 pm Thyroid (2) Monday 1–5 pm GI (4) 10/13/14

Appendix D: Example Case Study

Mr. Green is a 56-year-old patient admitted to the hospital with diabetic ketoacidosis . He has had Type II Diabetes Mellitus for 34 years. He has a past medical history of myocardial infarction, congestive heart failure (ejection fraction of 25 %), and rheumatoid arthritis. His admission blood glucose was 880 mg/dl; his ABG’s were as follows: pH = 7.23, HCO3 = 18, CO2 = 23. He was transferred from the ICU to the unit 2 days ago. His blood glucose levels have still been elevated but signifi cantly lower than on admit: last 24 h—ac breakfast—280 mg/dl; ac lunch—240 mg/dl; ac dinner—260 mg/dl. His current medications include: metoprolol 20 mg qd; lasix 40 mg po qd; coreg 3.25 mg qd; lantus 40 units every evening; sliding scale ac hs with NovoLog. Please answer the following questions: 1. Describe the pathophysiology of ketoacidosis. 2. Describe the clinical manifestations of ketoacidosis. 3. Discuss the medications that Mr. Green is taking. Why is he taking these medications? 4. Discuss the lab values. Are Mr. Green’s fi ndings consistent with the anticipated lab fi ndings? 5. What are the priority nursing actions with this admit diagnosis?

Appendix E: Example Welcome Letter

Dear (student name here), My name is (your name here) and I am pleased that I have the opportunity to work with you as your faculty advisor. We will work together to discuss the various expectations of nursing school and I can provide you with some strategies to promote your success. Your success in this nursing program is very important to me and I would like to meet with you prior to the semester so that we can discuss strategies to help you. Please provide me with a few days next week that you might be available. Thank you, (sign your name here)

Appendix F: Key Discussion Points During Advising

Ask questions such as: 1. Describe for me your typical week of classes. 2. Describe for me your study strategies during the week. 3. How long prior to a nursing exam do you start studying? Use the answer to this to assess if there is a necessary discussion regarding strategies to be successful in nursing school. If the student says they start studying a week before the nursing exam, that may simply not be enough and you may need to discuss a more realistic approach that aligns the student with more successful strategies. 4. Do you work? If so, how many hours per week? 5. Do you commute to school? 6. Do you live on campus? 7. How do you study? By yourself? With a study group? These are only a few of the possibilities but they can give you a lot of information regarding a student’s study habits. You may need to follow up with students periodi- cally based on their answers and their grades. These meetings should not preclude meetings with their course faculty to review the individual course examinations and discussions with the course faculty regarding success strategies.

Appendix G: Clinical Organization Tool

Room: Patient hx: LABS: Vital MEDS: (I write out times meds Student Perf. Student: Signs due). Example: Notes: Nurse: 0730 insulin MD: 0900 lasix IV 0900 Ancep IVPB Etc. **as they are given I scratch through Room: Patient hx: LABS: Vital MEDS: Student Perf. Student: Signs Notes: Nurse: MD: Room: Patient hx: LABS: Vital MEDS: Student Perf. Student: Signs Notes: Nurse: MD:

Appendix H: Example of Clinical Syllabus

School Name Here Course Name Here Clinical Syllabus Instructor : Insert name and content information (cell phone) Unit: Unit name and Contact Information Brief Description of Unit: Describe the types of patients that are typically on this unit Wednesdays : Preclinical: 1:30 to 3:30 --- Come straight up to the unit • Obtain clinical assignment. • Please acquire appropriate information to allow you to take appropriate care of your patient to include the medication administration record, past medical history, course of present stay, plan of care, lab work and diagnostics, care plan. • Your clinical faculty will inform you what can be printed out to utilize as a guide for medication administration. Do not print from the computer without permission. • Meet your patient—do not wake up if sleeping—sweep the room with your eyes—what equipment do you see? • Check with your instructor before leaving. • Paperwork that should be started prior to your ﬁ rst clinical day: – Care plan (nursing diagnoses, interventions completed at minimum) – Medication cards – Pathophysiology Important Clinical Information: • ALL MEDS must be checked by me prior to administration to the patient. I must be with you when you give medications. • Follow the medication administration process discussed in orientation. You may not administer medications with the nurse assigned to the patient (this is a school policy).

© Springer International Publishing Switzerland 2016 125 K.C. Harmon et al., Nurse Educator’s Guide to Best Teaching Practice, DOI 10.1007/978-3-319-42539-9 126 Appendix H: Example of Clinical Syllabus

• Prior to administering medications, you must verbalize knowledge of the medications that you will be administering. Information that you will be expected to know: – Drug classifi cation – Mechanism of action – Why is your patient receiving this medication? – Common adverse reactions/side effects – Nursing considerations—before, during, and after administration Vital signs Lab results Other considerations Suggested clinical organization : • Find nurse and obtain report on patient. Communicate with your nurse regarding the specifi c care that you will provide for the patient for the day. • Check your patient and check vital signs. Perform am assessment. • Check chart for new orders, progress notes, nurse’s notes, lab results, vital signs. • Perform ADLs. • Administer medications with instructor. • Perform noon vital signs and noon assessment (Accu-Chek if indicated). • Perform any treatments when indicated. • When shift complete, provide nurse with an update regarding your patient. Note: When you have two patients: Do not have both patients’ medications in your possession at one time. Meds may be checked with instructor, placed in plastic bag with patient’s name on bag, and locked in medication drawer (if not ready to administer yet). In Post Conference be prepared to discuss: • the care of your patient…in particular, any critical thinking you had to do in order to provide professional nursing care and/or…. • Anything you learned that day/week … • Any issues/concerns faced on clinical You are responsible for all policies from the Nursing Handbook regarding: • Absences • Dress code • No gum chewing on unit • No personal phone calls unless need for call discussed with instructor fi rst; turn phones off or place on vibrate • Professional behavior • Caring behavior Appendix H: Example of Clinical Syllabus 127

Other information: 1. If use the last supply (needles, syringes, etc.), please reﬁ ll for the next person. 2. A patient’s condition can change rapidly. Please notify your instructor and nurse if you note a change in the patient’s status. 3. If patient is scheduled for a test, be aware may be NPO a patient may or may not receive medications, depending on the doctor’s orders. Check this carefully . 4. We are not allowed to administer narcotics. The following is a list of the paperwork that is due each week by ____ (state the due date and time): list paperwork that is due. Questions?

Appendix I: Abbreviated Second Patient Form

Student Name ______

Date ______

Patient Admit Diagnosis: ______

Past Medical History: ______

Current Treatments: ______

List at least 5 medications and describe how why these medications are prescribed for your patient. 1) 2) 3) 4) 5)

Lab work relevant to admit diagnosis. Please explain why: ______

Three Priority Nursing Diagnoses: 1) 2) 3)

Appendix J: Example of a Clinical Contract

Student Name ______Course ______

Date ______Semester ______

The student is to reflect on and complete the following statements:

1) Please describe the situation requiring this clinical contract.

2) Has this happened before?

3) How could this behavior be harmful to the patient?

4) Plan for addressing the behavior to prevent recurrence.

Following the completion of the above section, the student and faculty will complete the area below together.

State the specific follow up required.

What will happen if the behavior occurs again?

Student Signature ______Date ______

Faculty Signature ______Date ______

Appendix K: Sample Action Plan

Student Name ______Course ______

Date ______Semester ______

The student is to reflect on and complete the following statements:

1) Please describe the situation requiring this clinical contract. I did not calculate the dose of the medication prior to entering the patient’s room. I had a syringe of 120 mg of Lovenox and had to administer 110 mg subcutaneously. I guessed at a proper dose instead of properly doing the calculation. 2) Has this happened before? This has not happened before. 3) How could this behavior be harmful to the patient? Since this is an anticoagulant, this could be problematic for the patient - especially if they have a potential for bleeding. 4) Plan for addressing the behavior to prevent recurrence. My first issue is that I need to work on my anxiety in clinical. I need to take time out to perform these important tasks.

Following the completion of the above section, the student and faculty will complete the area below together.

State the specific follow up required. The clinical instructor and student will meet weekly to assess progress toward goals.

What will happen if the behavior occurs again? The student will receive a formal unsatisfactory that will be placed in the student file.

Student Signature ______Date ______

Faculty Signature ______Date ______

Appendix L: Sample of Debrieﬁ ng Questions for Simulation

1. What went well? 2. What did not go so well? 3. What would you do differently? 4. What is the role of the primary RN in this situation? 5. What documentation should be completed? 6. What would the SBAR be about? 7. Did we need additional health care members for this situation? Who? Why?

Index

A Classroom incivility Abbreviated Second Patient Form , 129 causes , 39 Academic integrity civil behaviors , 39 , 40 Adult Health Nursing unit examination , 43 Class Codes of Conduct , 40 assignments , 45 defi nition , 38 cheating behavior , 43 faculty perceptions , 39 cheating, classroom exam , 45–46 nursing administration , 38 methods, students to cheat , 44–45 students’ perceptions , 39 Accreditation Commission for Education in Classroom teaching Nursing (ACEN) , 10 course lesson plan , 30 , 31 ACEN . See Accreditation Commission for course objectives (outcomes) , 30 Education in Nursing (ACEN) course syllabus , 29 , 30 ADN . See Associate Degree in Nursing engagement , 33–34 (ADN) faculty member , 27 , 28 Adult learners fl ipped classroom , 34–44 andragogy , 24 incivility (see classroom incivility ) characteristics , 24 , 25 LMS , 27 , 30–32 life experiences , 25 nursing program reciprocity and cooperation , 25–26 principles , 37 ASN . See Associate of Science in Nursing student retention and success , 37 , 38 (ASN) PowerPoint presentations , 27 Associate Degree in Nursing (ADN) , 9 pre-class assignment , 32 Associate of Science in Nursing (ASN) , 9 responsibilities and course preparation activities , 28 Clinical contract , 131 B Clinical experiences Bachelor of Science in Nursing (BSN) , 3 , 9 clinical instructor BSN Degree Program Outcome Measures , 113 assignments , 50 , 52 , 53 critical thinking , 53 , 54 organizational tool , 51 C organization, clinical day , 53 C A T . See Computerized adaptive testing post-conference , 54 (CAT) review students’ transcripts , 51 CCNE . See Commission on Collegiate student contact list , 51 , 52 Nursing Education (CCNE) conversations , 50 Certifi ed Nurse Educator (CNE) , 14 faculty role , 49

Clinical experiences (cont.) E feedback Educational technology (ET) , 90 paperwork , 64 Engagement performance , 64 discussion postings , 93 great intimidator , 65 learning activities , 93 professionalism , 66 online learning, nursing , 96 spending time with students , 59–60 sense of community , 97 supporting students, skills , 54–55 students , 92 today’s student teaching-learning process , 96 abuse prevention , 63 Exam blueprint , 115 characteristics , 60 differences , 60 impaired student , 62 I information , 61 Instructional design consultants (IDCs) , 82 outstanding student , 61 practice examples , 62 signs and symptoms, impairment , 63 K suspected impairment , 63 Ketoacidosis , 117 uncivil behavior , 65 unpreparedness, students baccalaureate program , 56 L clinical expectations , 56 , 57 Learning content management systems conversation, clinical faculty , 58 (LCMSs) , 86 decision making , 57 Learning management system (LMS) , 27 , management , 58–65 30–32 , 82 PEG , 56 academic dishonesty , 101–104 personal issues , 57 ADN program , 83 weak students , 59 cognitive level , 103 Clinical organization tool , 123 communication media , 101 Clinical syllabus , 125–127 community-based client’s home , 87 Commission on Collegiate Nursing Education defi nition , 86 (CCNE) , 10 discussion postings/formal assignments , 99 Computerized adaptive testing (CAT) , 11 educational technology , 90 Course examinations electronic interactions , 86 assessment format fi lters and access restrictions , 95 Bloom’s taxonomy , 41 growth , 86 instructional objectives and course information technology , 90 content , 43 leadership responsibilities , 87 KR score , 42 learner-to-learner interaction , 100 NCLEX-RN examination , 41 learning process, online environment , 85 question types , 41 by market share , 87 test review , 42 , 43 metacognition , 88 cheating (see Academic integrity ) metadata of documents , 104 test blueprint , 41 nursing education , 86 Course management systems (CMSs) , 86 online domain , 96 Course syllabus , 111–112 person-to-person contact , 95 plagiarism , 104 scheduling challenges , 103 D security and integrity , 103 Debriefi ng questions, simulation , 135 social presence , 99 Desire2Learn (D2L) , 97 web-based and print resources , 88 Diabetes mellitus , 117 written assignments , 104 Diabetic ketoacidosis , 117 LMS . See Learning management system Discussion points, advising , 121 (LMS) Index 139

N O National Council State Boards of Nursing Online learning (NCSBN) , 9–11 academic activity , 81 National League of Nurse Education accountability , 107 (NLNE) , 8 assignment feedback , 97 NCLEX-RN asynchronous content , 94 Bloom’s taxonomy , 10 classroom teaching , 82 C A T , 1 1 concept-based curriculum , 83 licensure , 10 constructivism , 91 practice analysis survey , 11 , 12 course delivery , 91 SBNs , 10 course information guide , 91 test plan, client needs , 10 , 11 distance education in nursing , 106 , 107 NCSBN . See National Council State Boards of enhanced electronic communication , 108 Nursing (NCSBN) entry-level skills , 90 NLNE . See National League of Nurse evidence-based practice , 82 Education (NLNE) instructors’ perceptions , 86–108 Nursing education introductory/biographical posting , 99 A Curriculum Guide for Schools of learning activities , 98 Nursing , 8 prevalence and growth , 85 A.D. program , 6 problem-oriented and solution-oriented assignments , 3 perspective , 89 catheterization kit , 2 real-time consultation , 98 changes , 7 remedial learning , 91 classroom teaching , 3 , 4 “reviewer” access , 90 clinical environment , 1 simulation, nursing education , 91 clinical skills , 4 synchronous content , 94 Committee for the Study of Nursing technological task , 92 Education , 8 therapeutic and productive learning curriculum and school rules , 5 communities , 9 8 diploma program , 1 educational goals , 1 educational pathways , 9 P faculty role , 13–14 Principles of teaching injections , 2 adult learners , 24–26 medications , 2 learning environment , 23–24 NCLEX-RN (see NCLEX-RN ) reﬂ ective practice , 21–22 NLNE , 8 student centeredness , 20–21 nontraditional students , 6 teaching philosophy , 22 nurse training programs, USA , 7 team , 22 nursing faculty , 3 vulnerability , 23 Nursing for the Future , 8 recovery rooms , 5 regulation, nursing schools , 9–10 R requirements , 5 Reﬂ ective practice , 21–22 Standard Curriculum for Nursing Schools , 8 student population , 12–13 S students, clinical assignments , 5 SBN . See State Boards of Nursing (SBN) teaching experience , 17 Seven principles of good practice teaching methods , 4 active learning , 18 test writing process , 4 description , 18 theoretical framework , 17 diverse talents and ways of learning , 19 treatment room , 2 emphasize time, task , 19 140 Index

Seven principles of good practice (cont.) management , 73 expectations , 19 medium fi delity , 71 prompt feedback , 19 mistakes and problems , 69 reciprocity and cooperation , 18 photo , 75 students and nursing faculty , 18 script , 72 Simulation student preparation , 73 adult learning principles , 71 theoretical framework anxiety , 77–78 advanced beginner , 70 assessment course , 69 competent , 71 Bloom’s taxonomy , 72 novice stage, beginners , 70 classroom learning , 71 profi cient and expert , 71 computer-based program , 71 unprepared students , 76 critical thinking , 69 State Boards of Nursing (SBN) , 10 , 13 debriefi ng , 73 Student centeredness , 20–21 description , 70 evaluation, student’s performance , 74 failure, students , 76–77 T high fi delity , 71 , 74 , 75 Teaching philosophy , 22 idea , 72 infusion , 70 learning objectives , 72 W low fi delity , 71 Welcome letter , 119