ASSURING THE COMPETENCY of nurses is of great PROMOTING CLINICAL COMPETENCE: USING SCAFFOLDED INSTRUCTION FOR PRACTICE-BASED LEARNING

Transcription

1 PROMOTING CLINICAL COMPETENCE: USING SCAFFOLDED INSTRUCTION FOR PRACTICE-BASED LEARNING DONNA SCOTT TILLEY, PHD, RN,* PATRICIA ALLEN, EdD, RN,y CATHIE COLLINS, MSN, RN,y RUTH ANN BRIDGES, MSN, RN,y PATRICIA FRANCIS, MSN, RN,y AND ALEXIA GREEN, PHD, RN, FAANz Competency-based education is essential for bridging the gap between education and practice. The attributes of competency-based education include an outcomes focus, allowance for increasing levels of competency, learner accountability, practice-based learning, self-assessment, and individualized learning experiences. One solution to this challenge is scaffolded instruction, where collaboration and knowledge facilitate learning. Collaboration refers to the role of clinical faculty who model desired clinical skills then gradually shift responsibility for nursing activity to the student. This article describes scaffolded instruction as applied in a Web-based seconddegree bachelor of science in nursing (BSN) program. This second-degree BSN program uses innovative approaches to education, including a clinical component that relies on clinical coaches. Students in the program remain in their home community and complete their clinical hours with an assigned coach. The method will be described first, followed by a description of how the method was applied. (Index words: Competency; Scaffolded instruction; Practice-based learning; Innovation) J Prof Nurs 23:285 9, A 2007 Elsevier Inc. All rights reserved. ASSURING THE COMPETENCY of nurses is of great interest to educators and administrators in practice disciplines, particularly health care disciplines. Bridging the gap between how recent graduates are educationally prepared and their readiness for practice is of interest to educators and employers (Scott Tilley, Allen, & Green, unpublished manuscript). The defining attributes of competency-based education remain somewhat nebulous but can be distilled down to the following: application of skills in all domains for the practice role, instruction that focuses on specific outcomes or competencies, allowance for increasing levels of competency, accountability of the *Associate Professor and Director, Texas Christian University, Fort Worth, TX. yassociate Professor, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, TX. zdean and Professor, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, TX. Address correspondence to D.Tilley@TCU.edu, patricia.allen@ttuhsc.edu, cathie.collins@ttuhsc.edu, ruthann.bridges@ttuhsc.edu, patricia.francis@ttuhsc.edu, alexia.green@ttuhsc.edu /$ - see front matter learner, practice-based learning, self-assessment, and individualized learning experiences (Scott Tilley et al., unpublished manuscript). It is increasingly clear that traditional didactic methods of education are not adequate to support competency-based education. The learning environment for competency-based education will necessarily involve the learner in assessment and accountability, provide practice-based learning opportunities, and individualize learning experiences. One solution to this challenge for nurse educators may be found in the use of scaffolded instruction. Scaffolded instruction allows for involving the learner in assessment, learner accountability, practice-based learning, and individualized learning experiences. Scaffolded instruction is a derivation of the theory of Vygotsky (1978), where cognitive processes, as they relate to peer cooperation and interaction, can be effectively applied in a clinical setting to promote higher level learning in nursing students. Vygotsky proposed that communication by hearing, reading, and observing body language was the critical element in learning (Pass, 2003). He postulated that learning could not be broken down into parts but that Journal of Professional Nursing, Vol 23, No 5 (September October), 2007: pp A 2007 Elsevier Inc. All rights reserved. doi: /j.profnurs

2 286 SCOTT TILLEY ET AL people perceive organized patterns as they learn (Pass, 2003). Vygotsky believed that social interaction could not be separated from learning that learning occurs only in the context of social interaction (Vavilis, 2003). Scaffolding is an instructional technique whereby collaboration, or social interaction, and knowledge are combined to facilitate learning. In this method, collaboration refers to the role of clinical faculty as they model the desired learning strategy or clinical skill, and then gradually shift the responsibility for the skill or nursing activity to the student. The knowledge component of this technique involves posing questions that gradually lead students from easy or familiar examples to new understanding. This teaching strategy, also known as guided practice, is effective for learning critical thinking skills and clinical decision-making skills (Peterson & Walberg, 1979; Rosenshine, 1983). Guidelines for scaffolding were summarized from the literature by Hogan and Pressley (1997) and include preengaging with the student and the curriculum, establishing shared goals, actively diagnosing student needs, providing tailored assistance and feedback, and assisting the student to generalize the content to other contexts. This article describes the innovative use of the scaffolded instruction method as it was applied in a Web-based second-degree bachelor of science in nursing (BSN) program. This second-degree BSN program uses many innovative approaches to education, including a clinical component that relies heavily on clinical coaches or preceptors. Students in the program remain in their home community and complete their clinical hours with an assigned clinical preceptor or coach. The method itself will be described first, followed by a description of how the method was applied in the second-degree BSN program. Characteristics of the Scaffolded Instruction Method A key principle of effective teaching occurs when individual student achievement increases after students experience direct teaching or supervision (Ellis, Worthington, & Larkin, 1994). Although the traditional model allows for a student to have access to a clinical teacher who is shared among 7 11 other students, scaffolded instruction allows for direct one-on-one supervision by an expert nurse. The ultimate learning goal of the scaffolded instruction method is scaffolding. Scaffolding is characterized by a collaborative interaction between a coach and a student whereby the coach serves to assist the student in the construction of knowledge from experiences and observations. Scaffolding allows for the coach to offer support and approval to the student while directing the student s activities and observations. Reaching the goal of scaffolding occurs in phases. These phases include imitation, collaboration, and, finally, scaffolding. Imitation occurs when persons of asymmetric expertise engage in activities that are independent and noncollaborative (Granott, 1993). Expertise is asymmetric when the coach, as expert, collaborates with the novice student. The student imitates the actions based on visual information. Verbal information, although helpful, is not required for imitation. The student observes the coach conducting an activity and is able to imitate the activity. As the knowledge of the student expands, the interaction between the coach and the student evolves to one of collaboration (Granott, 1993). Collaboration occurs when persons of asymmetric expertise collaborate toward a common goal. The student s expanded knowledge base allows interaction with the coach in a way that is spontaneous, is collaborative, and enhances the understanding of both about the shared situation (Granott, 1993). As the student and the coach engage in routine activities of nursing, the student s understanding of shared activities is enhanced by spontaneous instructions made possible by a comfortable relationship in the dyad. Expansion of student knowledge, coupled with a developing relationship between student and coach, contributes to the development of counterpoint. Counterpoint is a collaborative interaction among persons with asymmetric expertise that results in shared feedback with an independent construction of understanding (Granott, 1993). In other words, the teacher learns along with the student. Discussions between expert coaches and novice students with a one-way flow of information from coach to student actually enhance understanding by the coach. Coaches then improve their own knowledge and understanding as a result of frequent contact with their student. Ultimately, counterpoint can become symmetric when two persons of equal expertise interact in an activity. Passive participants, or listeners, in this process are readily able to learn from the interaction of active participants (Granott, 1993). The student s relationship with one consistent nurse exposes the student to many encounters that model symmetric counterpoint as expert nurses solve problems together. Even the passive participation of listening as two or more experts problem solve together creates cognitive change in the listener (Granott, 1993). As the student s knowledge base expands, the student and the coach may eventually be able to interact on a level of equal expertise on some topics and readily learn from each other. Learning reinforcement, eagerness to learn, and further engagement in clinical practice occur when the students perceives themselves to be bpart of the team.q One of the positive but unanticipated outcomes of using coached scaffolded instruction with these students is the strong and positive relationship that develops between the student and the coach. Spouse (2001) identified the concept of a theory/practice gap in nursing education as the basis for using scaffolding in a study of mentorship in clinical experiences for eight nursing students. Spouse found that the establishment of a solid mentor/student relationship was

3 PROMOTING CLINICAL COMPETENCE 287 critical and that the absence of such a relationship inhibited learning. Confidence was established in the students when they were befriended by their mentor. When the mentor took time to assess what the student knew and needed to know, a collaborative relationship developed. Through the collaborative relationship, scaffolding was employed by using what the student already knew to build on the acquisition of new skills, thus enhancing confidence. One method used by mentors was thinking aloud while using clinical judgment to care for patients. Application of the Method in a Second-Degree Program Scaffolded instruction is the foundation for the delivery of a Web-based second-degree BSN curriculum that currently gathers data on areas of technology integration in online education for students who remain in their home community while obtaining a BSN degree in 12 months. Preceptors, or clinical coaches, are critical to the success of the method. The coaching method allows clinical education to occur in a qualified acute care facility in the community where the student resides. Qualified facilities have been approved by the program director and support all needed clinical experiences. Selected clinical coaches have BSN as minimum degree, 3 years experience as registered nurse, a written recommendation from the facility s director of nursing, and a signed agreement of willingness to work with the student for 12 months. Clinical facilities are selected to provide a wellrounded medical/surgical clinical experience. Intermediate care units where the nurse:client ratio is lower, client acuity is higher, and state-of-the-art technology for client care delivery is available are ideal areas for student placement. Each coach and student is provided with a personal digital assistant and the most current clinical software available. As coaches utilize current technology, such as computerized charting, medication systems, and personal digital assistants, students become comfortable with utilizing technology in their own practice. Preparing Clinical Coaches for Their New Role Coaches are oriented to the preceptor role by participating in a 1-day workshop, which reviews the BSN educational program, their roles and responsibilities, and the weekly clinical objectives for the program. Coaches are also oriented to the use of a coaching card. This card provides a structure for posing questions in the clinical setting, which gradually lead students to critical thinking of increasing depth and clinical decisionmaking skills (Table 1). With the use of the coaching card, the coach can consistently identify what the student knows, begin with what the student can do for the client, help the student achieve early success in client care delivery, and allow independence when the student has command of client activity (Chang, Sung, & Chen, 2001). Associated course materials are provided to all Table 1. Coaching Card Critical Thinking Synthesize data/ problem label Management Urgency Interpersonal!What is the problem?!what complications could occur?!what clinical data would lead you to believe that this complication will occur?!what nursing actions do you need to take and why? Communicate with physician/anticipate physician s orders Give multiple opportunities for the student to observe you calling physicians and assist with communication with physicians!what data are we going to give the physician?!why are these orders needed?!what clinical data would indicate that the patient needs immediate intervention and why? If an action(s)/intervention taken by the student is irrelevant, causes harm, or has potential for harm, ask: What makes your action unacceptable/undesirable? What action should have been taken? Discuss incidents describing either negative or positive outcomes!who was involved?!the issue of conflict!the intended or desired outcome and the interpersonal strategy used!results of the strategy!if the outcome is negative, discuss alternative strategies or responses Note. Review these incidents with the student to help the student develop interpersonal skills and gain insight about personal communication. clinical coaches via access to a WebCT communication forum and access to online courses of the BSN program. At the program midpoint, coaches return to campus for an opportunity to further dialogue with each other and with program faculty on student progress, to share clinical scaffolded instruction techniques that have been beneficial in the coaching role, and to participate in interviews with outside educational consultants to obtain rich data on salient events occurring in the use of this method for clinical learning. Student/Coach Interaction Coaches are selected based on previously noted criteria, but special attention is given to select coaches and students who will work well together. This relationship is meant to last for three intensive clinical courses, which span the 12 months of the program. During this time, the student spends up to 24 hours/ week with the coach in an acute care setting. An interactive and collaborative relationship between the

4 288 SCOTT TILLEY ET AL coach and the student is essential in this process. Clinical immersion happens rapidly as this adult learner moves from shadowing the coach to performing nursing activities at a pace set by the faculty/coach and adult learner. Each week, the students and their coaches focus on weekly objectives salient to the current course. These objectives are implemented based on opportunities available in the assigned facility. The coached experience allows second-degree BSN students to have one-on-one attention for their clinical learning experiences and a one-to-one mentored relationship. The coach develops interpersonal knowledge of the student s learning style, which allows the coach to recognize cues such as student frustration and the bi-got-it moment,q and cues when it is time to stop pushing the student to achieve quick success. This interpersonal insight, although intangible, is a valued component of this dyad. Faculty/Coach Interaction Faculty for the second-degree program were selected based on their experience with Web-based teaching and their commitment to innovation in teaching and in recognizing a changing paradigm of nursing education with a focus on alternative delivery models. These seasoned faculty members bring with them expertise in their specialty areas of nursing practice. They have advanced technology and Web-based teaching skills, and they create and deliver the course content using a variety of online teaching methodologies utilizing a WebCT platform. Faculty use their extensive knowledge of clinical teaching, and the use of scaffolded instruction for clinical teaching can encourage collaboration and knowledge between the coach and the student for the facilitation of learning. Program faculty are readily available to students and coaches. The curricular model for clinical supervision and teaching requires a 5:1 student:faculty ratio in the start-up year of the program. This faculty member orients each student to health care facilities, attends two on-site School of Nursing orientations for selected coaches, and visits each student and coach every 5 7 days in the entire semester. Individual student performance may require the assigned clinical faculty to visit more frequently. Clinical faculty are readily available to all assigned students and coaches by phone, , and WebCT communication. Visits to the clinical setting allow faculty to assess the student/coach relationship for learning, to provide needed consultation to the coach or the student, to provide support to coaches in their roles, and to evaluate the student in the clinical setting in relation to safe performance and ability to meet the assigned weekly clinical objectives. Visits throughout the entire semester provide opportunities for student/faculty/ coach dialogue about curricular topics, clinical concerns, areas for professional growth, and professional socialization through faculty role modeling. Faculty evaluate the student in the clinical setting at least weekly or as needed. Evaluation by faculty is based upon a direct observation of student performance. Coaches also evaluate students at least weekly or as needed based upon direct observation. Benefits of Scaffolded Instruction The nursing shortage has stimulated a huge market for nurses. Increasing enrollment in nursing programs is one of the key steps in addressing the current nursing shortage, which is projected to be severe and long term (American Association of Colleges of Nursing [AACN], 2005). Although enrollment in nursing schools nationwide has increased, N 32,000 qualified applicants were turned away from baccalaureate and graduate programs in 2004 (AACN, 2005). Accelerated programs are important in addressing the nursing shortage because they produce bachelor s-prepared nurses quickly and efficiently (AACN, 2005). In 2004, 22 new accelerated nursing programs were launched, bringing the total number of these programs in the United States to N 150. Faculty evaluate students in the clinical setting weekly using the designated clinical evaluation tool, direct observation of student performance, coach input concerning weekly performance of the student, and student input from a self-evaluation of the attainment of weekly clinical objectives. This method encourages the student to remain in one s community following program completion and provides the coach s facility with a new graduate who needs very little institutional orientation upon employment. Many of the enrolled students reside in rural settings and are currently completing the program within their rural community, addressing the need for rural nurses. Student learning is enhanced with a model that allows the student to feel comfortable in one clinical setting in an extended period with a consistent information source the coach. Practice at the bedside is enhanced with the impact of the coach consistently role modeling expert nursing and the coach being open to the wealth of evidence-based knowledge that the student brings to the relationship. This is partially due to the coach/student synergy that emerges at the bedside and the use of a 21st-century curriculum built on the integration of technology and best practices. Conclusion The assurance of competence in nurses at entry level and in practice is essential, especially in the face of expectations for increased accountability by health care consumers and administrators. The changing health care environment is complicated by a long-term nursing shortage and requires innovative approaches to nursing education. One way to achieve competence in new graduates is through the use of scaffolded instruction. Although innovative, this method adheres closely to standard principles of effective teaching (Ellis et al., 1994) by providing active engagement, more direct time with a coach in the clinical setting, and the formation of

5 PROMOTING CLINICAL COMPETENCE 289 an independent learner who is capable of critical thinking and contextual decision making. Additionally, the method allows for the elements of competency-based education: application of skills in all domains for the practice role, instruction that focuses on specific outcomes or competencies, allowance for increasing levels of competency, accountability of the learner, practice-based learning, self-assessment, and individualized learning experiences. The use of scaffolded instruction, coupled with a clinical coaching model, offers many benefits over traditional models of clinical education. The clinical coach model facilitates the total immersion of the student into the practice setting for clinical application of knowledge through scaffolding. Using this method, students are able to stay in their local communities and receive one-on-one attention from an expert nurse. The relationship that develops facilitates contextual learning, which allows for immediate application in practice. References American Association of Colleges of Nursing (AACN). (2005). New data confirms shortage of nursing school faculty hinders efforts to address the nation s nursing shortage. Washington, DC: Author. Chang, K. E., Sung, Y. T., & Chen, S. F. (2001). Learning through computer based concept mapping with scaffolding aid. Journal of Computer Assisted Learning, 17, Ellis E., Worthington L., & Larkin M. (1994). Executive summary of the research synthesis on effective teaching principles and the design of quality tools for educators. Eugene College of Education, Oregon University. Granott, N. (1993). Development in context: Acting and thinking in specific environments. In R. Wozniak, & K. Fischer, (Eds.), The Jean Piaget symposium series, 1993 (pp ). Hillsdale, NJ: Lawrence Erlbaum Associates Publishers. Hogan, K., & Pressley, M. (1997). Scaffolding student learning: Instructional approaches and issues. Cambridge, MA: Brookline Books. Pass, S. (2003). A biographic comparison tracing the origin of their ideas of Jean Piaget and Lev Vygotsky. American Educational Research Association Proceedings. Peterson, P. L., & Walberg, H. J. (1979). Research on teaching. Berkeley: McCutchan. Rosenshine, B. (1983). Teaching functions in instructional programs. The Elementary School Journal, 83, Scott Tilley, D., Allen, P., & Green, A. (unpublished manuscript). Competency in nursing: A concept analysis. Unpublished manuscript. Spouse, J. (2001). Bridging theory and practice in the supervisory relationship: A sociocultural perspective. Journal of Advanced Nursing. Blackwell Publishing ovid.com/gw2/ovidweb.cgi. Vavilis, B. (2003). Implication of John Dewey s and Lev Vygotsky s theoretical frameworks for the teaching and learning of 10th grade geometric proofs. Unpublished manuscript. Vygotsky, L. (1978). Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press.