NUR 634 Module 6 Clinical Teaching Analysis Example

Clinical Judgment at the Bedside: Analyzing and Redesigning a First-Semester Clinical Day

[Student Name]

Southern New Hampshire University

NUR 634: Facilitating Learning and Teaching Innovation in Nursing Education

Module Six Clinical Teaching Analysis

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Clinical Judgment at the Bedside: Analyzing and Redesigning a First-Semester Clinical Day

Clinical placements consume a large share of nursing program resources, yet what students actually do during a clinical day is rarely analyzed. Faculty are often stretched across eight or more students, spending their time on safety checks for medications and procedures, while the clinical judgment the placement is meant to build is left to chance. This paper analyzes one instructor's clinical day, uses a clinical judgment model and rubric to reframe what the day should accomplish, weighs two alternatives to the traditional model and proposes a redesign. It argues that small, deliberate changes in how faculty spend their time and give feedback can turn the clinical day into sustained practice of clinical judgment.

An Instructor's Day, Measured

The composite instructor supervises eight second-semester associate degree students on a 30-bed medical unit, each caring for one patient. For one eight-hour shift, she recorded her activities in 15-minute blocks. About 55% of her time went to supervising medication administration, since program policy requires faculty to be present for every student medication pass. About 15% went to procedures such as dressing changes, 10% to communicating with staff nurses and 10% to charting review. Only about 10%, roughly 45 minutes spread across eight students, went to conversations about what students were noticing and how they were interpreting it. Post-conference, the one scheduled time for reflection, often shrank to 20 minutes because students were finishing documentation. When the instructor looked back at her notes, she could recall a specific judgment conversation with only three of the eight students, and for two students the only feedback she had written all day concerned medication technique. None of this reflects a lack of skill or care; it reflects a clinical model in which one instructor is legally and practically responsible for eight students' safety and has little time left for anything else.

Reframing the Day Around Judgment

In Tanner's account, clinical judgment moves from noticing through interpreting and responding to reflecting, and reflection is what turns clinical experience into knowledge (Tanner, 2006). Measured against that model, the instructor's day gives students practice in responding, mainly through tasks, but little structured support for noticing, interpreting or reflecting. The Lasater clinical judgment rubric offers a practical way to change this. Lasater built it on Tanner's phases after watching students in simulation; it breaks judgment into 11 observable behaviors, from how purposefully a student observes to how willingly she evaluates her own performance, and places each behavior on a four-step scale that runs from beginning to exemplary (Lasater, 2007). That structure gives faculty and students a shared language for talking about judgment and a way to track growth across a term.

Alternative Models

Two alternatives to the traditional model deserve consideration. In the dedicated education unit, a hospital unit and a school jointly prepare staff nurses to serve as clinical instructors for students, with faculty coaching the staff nurses and overseeing learning. An implementation across six units in three hospitals reported high satisfaction among students and nurses and a marked increase in clinical capacity that allowed higher enrollment (Moscato et al., 2007). The model could free faculty from routine supervision and let them focus on judgment, but it requires a hospital partner willing to invest in staff development.

Simulation is the second alternative. In the NCSBN National Simulation Study, graduates whose programs replaced up to one clinical hour in two with carefully run simulation matched their peers on competency ratings and on first-attempt licensure results, although the programs involved had trained simulation faculty and debriefed with a theory-based method (Hayden et al., 2014). For Riverbend, where faculty are stretched and placements are scarce, substituting a modest share of clinical hours with well-debriefed simulation could concentrate judgment practice in a setting built for it.

A Redesigned Clinical Day

The redesign keeps the traditional placement this term but changes how time is used. First, medication supervision will be shared: after students pass a medication competency check in the second week, the staff nurse assigned to each student's patient, briefed by the instructor, will observe routine oral medications, with faculty still present for high-alert drugs and injections. This frees roughly two hours of faculty time. Second, faculty will use that time for brief bedside conversations with each student, twice a shift, built on a small set of questions: What did you notice when you first saw your patient? What do you think is going on? What would make you worried? What will you check next? Third, post-conference will be protected at 45 minutes by ending patient care 15 minutes earlier, and it will follow the four phases, with each student presenting one moment from the day. Fourth, the Lasater rubric will guide feedback, and students will receive a copy in the first week so they know the language faculty will use, with faculty focusing on one dimension from each phase each week, so that over the term every student receives written feedback on all 11 dimensions.

Evaluating the Change

The instructor will repeat the time log in week eight, using the same 15-minute blocks, to see whether time spent on judgment conversations has increased from about 10% toward a target of 30%. Students' Lasater ratings on the four phases will be compared between week three and week twelve, and students will be asked at midterm whether the bedside questions helped them think about their patients. Staff nurses will be asked whether sharing medication observation affected their workload, and any medication events involving students will be reviewed to make sure the change has not reduced safety. If the time log shows no gain or safety concerns appear, the sharing arrangement will be revised with the unit manager before the next term.

Conclusion

The clinical day at Riverbend, like many, gives students practice in tasks while leaving clinical judgment largely to chance. Measuring how faculty time is spent, adopting the Lasater rubric as a shared language, sharing routine supervision with staff nurses, protecting post-conference and asking the same judgment questions at every bedside can make the day a deliberate practice of thinking like a nurse. Dedicated education units and simulation offer larger changes for the future.

References

Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2 Suppl.), S3-S40. https://doi.org/10.1016/S2155-8256(15)30062-4

Lasater, K. (2007). Clinical judgment development: Using simulation to create an assessment rubric. Journal of Nursing Education, 46(11), 496-503. https://doi.org/10.3928/01484834-20071101-04

Moscato, S. R., Miller, J., Logsdon, K., Weinberg, S., & Chorpenning, L. (2007). Dedicated education unit: An innovative clinical partner education model. Nursing Outlook, 55(1), 31-37. https://doi.org/10.1016/j.outlook.2006.11.001

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. https://doi.org/10.3928/01484834-20060601-04