Undergraduate training in the care of the acutely ill patient: a literature review

Objective To characterise the problem of teaching acute care skills to undergraduates and to look for potential solutions. Design Systematic literature review including Medline, EMBASE, CINAHL. Eligible studies described education and training issues focusing on caring for acutely ill patients. Articles were excluded if they did not address either educational or clinical aspects of acute care and resuscitation. Measurement and results We identified and reviewed 374 articles focusing on training or clinical aspects of caring for the acutely ill patient. Undergraduates and junior physicians lack knowledge, confidence and competence in all aspects of acute care, including the basic task of recognition and management of the acutely ill patient. There is wide variability both between and within countries regarding the amount of teaching in critical care offered to undergraduate medical students. Many centres are starting to use an integrated approach to acute care teaching, with early exposure to basic life support and clinical skills, coupled with later exposure to more complex acute care topics. Clinical attachments remain a popular method for training in acute care. Acute care courses are increasingly being used to standardise delivery of practical skills and patient management training. Conclusion The training of healthcare staff in the care of acutely ill patients is suboptimal, adding to patient risk. Improvements in training should start at undergraduate level for maximal effect, should be integrated with postgraduate education, and are likely to enhance current efforts to improve patient safety in acute care. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users     

Acute care teaching in the undergraduate nursing curriculum

Aim:  To incorporate basic aspects of acute care into the undergraduate nursing programme by providing an opportunity for the development of knowledge and skills in the early recognition and assessment of deteriorating patients on general hospital wards.
Background:  Acute care initiatives implemented in the hospital setting to improve the identification and management of 'at risk' patients have focused on the provision of education for trained or qualified staff. However, to ensure student nurses are 'fit to practice' at the point of registration, it has been recommended that acute care theory and skills are incorporated into the undergraduate nursing curriculum.
Practice development initiative:  An 'Integrated Nursing Care' module was incorporated into year 3 of the undergraduate nursing programme to introduce students to acute care theory and practice. Module content focuses on the early detection and management of acute deterioration in patients with respiratory, cardiac, neurological or renal insufficiencies. We used a competency-based framework to ensure the application of theory to practice through the use of group seminars. High-fidelity patient-simulated clinical scenarios were a key feature. The United Kingdom Resuscitation Council Intermediate Life Support course is also an important component of the module.
Conclusions:  Incorporating the Integrated Nursing Care module into the undergraduate nursing curriculum provides pre-registration students the opportunity to develop their knowledge and skills in acute care.
Relevance to clinical practice:  The provision of undergraduate education in care of the acutely ill patient in hospital is essential to improve nurses' competence and confidence in assessing and managing deteriorating patients in general wards at the point of registration.     

Peer learning partnership: an innovative strategy to enhance skill acquisition in nursing students

The development of clinical skills for nursing students is a critical component of any undergraduate nursing program. Providing sufficient quality experience for students to develop competence has been recognised as a problem in skill acquisition. At the same time, peer learning has been identified as a valuable strategy for teaching and learning. Nurse academics at a Sydney university recognized these facts and implemented a peer learning strategy into existing first and third year nursing therapeutics units of study. This innovative approach linked the Australian Nursing Council Inc (ANCI) standards of practice to skills acquisition, resulting in third year students increasing their understanding of the relevance of these competency standards to practice. The peer learning strategy involved partnering first and third year students for clinical skills practice sessions. Evaluation of the peer learning approach indicated students valued the experience.     

Mental Health Education and Virtual Learning Environments (VLEs) in Pre-registration Nursing Degrees: Follow the Leaders?

Virtual learning environments (VLEs) are now commonly used, worldwide, as teaching and learning platforms for pre-registration nursing education. However, there is only limited evidence in the research literature to suggest that VLEs are employed to support the education of student nurses about mental health and illness. This article describes the work of mental health nurse educators who have taken the lead by providing case-based simulations on VLEs, thereby enabling students to acquire knowledge and develop the clinical skills required for practice in mental health settings. Benefits of VLEs include their flexibility and accessibility, and also the opportunity they provide for students to engage with Web 2.0 technologies. Leadership in education must include the utilization of the most current pedagogical tools and strategies, as well as staying abreast of contemporary evidence-based practices in clinical settings, to support the knowledge acquisition and practice-based learning of the registered nurses (RNs) of the future.     

Preparing Nursing Students for Mental Health Care: The Impact of a Recovery-oriented Clinical Placement

The provision of mental health care has recently focused on the concept of recovery-oriented care. Clinical placements are important for imparting recovery-oriented knowledge and skills to students. However, it has been determined that not all clinical placements are beneficial for future nursing professionals. The aim of this study was to examine what elements of professional learning were facilitated by engagement in a recovery- and recreation-based clinical placement for pre-registration nursing students called Recovery Camp. Qualitative data were collected through individual interviews and reflective journals of pre-registration nurses. Findings from this study indicate that Recovery Camp enhanced students' understanding of stigma, developed their professional knowledge and applied skills, and helped them gain insight into the role a consumer plays in his/her own recovery journey. Placements that allow pre-registration nurses the opportunity to authentically engage with people with a lived experience of mental illness may assist in the effective development of future professionals in meeting their diverse needs.     

Incomplete holism in pre-registration nurse education: the position of the biological sciences

There is an ongoing debate in nurse education concerning the role and delivery of the biological sciences in the nursing curriculum. One of the fundamental questions raised by this debate asks how best can teachers impart biological knowledge in a manner that can be readily applied by students and qualified nurses to inform their clinical practice. This paper will include a discussion of some of the features of pre-registration education that may have influenced the manner in which biological sciences are perceived, taught and used by nurses. It will be argued that nursing may have developed a form of incomplete holism and that this may be in part responsible for the challenges that remain to be met within this area of the nursing curriculum. As a response to incomplete holism an innovative approach within pre-registration education will be introduced. This development involves the use of linked teaching sessions which aim to develop the analytical skills necessary to apply physiological knowledge to nursing practice.     

Promoting active learning using audience response system in large bioscience classes

This paper considers the challenges of bioscience teaching and learning in pre-registration nurse education. Effective learning requires active student participation which is problematic when teaching large groups of students. New technologies, such as the audience response system (ARS), have been introduced to increase student participation and support them in the understanding of complex bioscience concepts. Within one university department, an evaluation was undertaken to identify the perceptions of pre-registration nurse students on the use of ARS in the teaching and learning of bioscience. Our findings concur with others that ARS increases student participation and aids in identifying misconceptions and in correcting them. Students found ARS very useful and wanted ARS to be used in additional modules too. Although ARS did not seem to motivate students to study adequately before attending the relevant sessions, it increased discussion among students and awareness of their level of knowledge compared to their peers. Further research is required to identify the effectiveness of ARS in the teaching and learning of bioscience and its impact on the performance of the students in their final assessments.     

The feasibility of introducing an evidence based practice cycle into a clinical area: An evaluation of process and outcome

The aim was to examine the feasibility of introducing an evidence based practice (EBP) cycle into a practice area within an undergraduate pre-registration programme. The cycle involved four meetings over five weeks on a cardiac intensive care unit. Three 3rd year adult branch nursing students participated with their mentors. A web page for the project was developed to support the process. Evaluation focused on changes in EBP knowledge and skills and issues around implementation and perceived value of the EBP cycle. The findings showed that the EBP cycle was straight forward to set up and was recognised as being of value by both students and mentors. The students demonstrated modest improvements in EBP knowledge and skills. The main problems were lack of time and difficulties in accessing on-line resources.     

Use of experiential methods to teach research in a pre-registration nursing curriculum

For nursing to become firmly established as a research-based profession, it is essential that all nurses are equipped with the skills to critique research literature. This demands the integration of research application into nursing curricula at all levels. In order for nursing problems to be effectively illuminated, it is important that a range of quantitative and qualitative approaches are utilised. This necessitates teaching material from across the range of relevant research paradigms. Many students commencing pre-registration courses have a limited knowledge of either nursing or research. Others have had a variety of previous experiences of research as a subject, some of which have generated negative stereotypes and disinterest. This paper will explore the challenges encountered when teaching research to students on a pre-registration advanced diploma course. The authors have developed a range of experiential exercises which attempt to explore research concepts in a meaningful way. The presentation of research principles is followed up by formative work linked to clinical placements. Discussion during feedback sessions allows for sharing of ideas and experiences within the group and facilitates critical reflection. The evaluation from this initiative has been positive and encouraging. A selection of the methods used and evaluation material will be presented.     

OSCEs--seven years on the bandwagon: the progress of an objective structured clinical evaluation programme

The original purpose of Objective Structured Clinical Examination (OSCE), as first described in the medical literature [Harden, R.M., Stevenson, M., Downie, W.W., Wilson, G.M., 1975. Assessment of clinical competence using objective structured examination. British Medical Journal, 1, 447-451], provided a means of examining the skills acquisition of medical students. A review of the literature, since that time, provides the background to the development of OSCEs into pre-registration nursing curricula, with the OSCE programme at the University of Salford presented here as a case study. The original student sample was a mixture of 150-250 adult, child and mental health students in each of seven cohorts over a period of four years. Each student undertook a 30-min formative, simulated patient, holistic care OSCE in their second year of the programme. Later developments included one remote workstation connected to and as part of the holistic patient care encounter. In subsequent curricula, the larger cohorts of around 250-300 students were accommodated in a formative rotational three-workstation OSCE, based on clinical skills to be acquired prior to their first clinical placement. A summative patient-centred OSCE was undertaken in practice at a later date. The educational and practice value of OSCEs regarding their clinical content and context in nursing curricula now and in the future are explored, along with the practicalities of implementation.     

Liberating new talents: an innovative pre-registration community-focused adult nursing programme

The drive for a more community-focused approach to pre-registration nursing education as identified in Modernising Nursing Careers, (Department of Health, 2006a) has continued to gather momentum. The research literature identifies that the community context impacts significantly on care delivery, with student nurses often missing the underlying complexities of working in this context; focusing on the task in hand rather than the broader landscape of care (Carr, 2004). In 2008, a community focused pre-registration adult nursing degree pathway was started at Canterbury Christ Church University (CCCU), to prepare a cohort of 16 nursing students to work in the community and general practice setting at the point of registration. Placement learning has been focused within general practice and community through a hub and spoke approach to enable students to develop a deep understanding of the complexities of care in this setting with particular reference to the management of risk and unpredictability. The pilot is being formally evaluated with a particular emphasis on the meaning and relevance of practice learning within these settings. The emerging data will not only provide evidence to promote the community and general practice agenda within pre-registration curricula, but help to clarify the essential skills and knowledge required to prepare students nurses for working in these settings.     

Cultural aspects of communication in cancer care

Cultural competence in oncology requires the acquisition of specific knowledge, clinical skills, and attitudes that facilitate effective cross-cultural negotiation in the clinical setting, thus, leading to improved therapeutic outcomes and decreased disparities in cancer care. Cultural competence in oncology entails a basic knowledge of different cultural attitudes and practices of communication of the truth and of decision-making styles throughout the world. Cultural competence always presupposes oncology professionals’ awareness of their own cultural beliefs and values. To be able to communicate with cancer patients in culturally sensitive ways, oncologists should have knowledge of the concept of culture in its complexity and of the risks of racism, classism, sexism, ageism, and stereotyping that must be avoided in clinical practice. Oncologists should develop a sense of appreciation for differences in health care values, based on the recognition that no culture can claim hegemony over others and that cultures are evolving under their reciprocal influence on each other. Medical schools and oncology training can teach communication skills and cultural competence, while fostering in all students and young doctors those attitudes of humility, empathy, curiosity, respect, sensitivity, and awareness that are needed to deliver effective and culturally sensitive cancer care.     

Student experiences and mentor views of the use of simulation for learning

This paper presents the findings of a two phase mixed methods study. Phase 1 investigated whether simulation could support the development of a range of clinical skills amongst pre-registration adult and children's nursing students. The second phase of the study gathered mentors' views and experiences of the use of simulation in the preparation of students for practice. Commissioned by the Nursing and Midwifery Council, the United Kingdom (UK) professional body, the study is reported as one of 13 pilot sites using designated practice hours for simulation. The commission resulted from a call to review the current pre-registration nursing curriculum that includes 4600 equally divided theory and practice hours delivered across the programme. Phase 1 included a sample of 69 adult and children's pre-registration students from years one and three of their programme, studying at one UK University. The group attended five simulation sessions including basic life support, manual handling, infection control, clinical decision making and managing violence and aggression. Students completed pre- and post-tests in basic life support and manual handling, and vignettes and objective structured clinical examinations (OSCEs) covering the five areas of simulation. Phase 2 included interviews with six mentors who were supervising students involved in the study. Simulation was positively received by both students and mentors as it was apparent that it offered scope for interdisciplinary learning that could be broadened to inter-professional applications. The study also identified that the use of simulation could provide scope for collaborative working between education providers and clinical staff.     

Face-to-Face and blended methods to improve oral competence in nursing students through simulation

Communication and interpersonal skills are relevant to the health professions, so it is important to promote these competencies at university. This research assesses the effectiveness of teaching oral competence through simulation using face-to-face and blended methods. A public speaking workshop was conducted in a group of 144 first year nursing students. Three groups were obtained according to the teaching method (Group 1: traditional method-3 sessions, Group 2: traditional method-2 sessions, Group 3: blended method-2 sessions). Public speaking confidence was measured at the beginning and end of the training, and oral competence was assessed at the end. As a result, all groups achieved a good level of oral competence after the training. However, while students in Group 1 showed greater oral competence, with regard to confidence in public speaking, students in Group 1 showed significantly worst results than those in Group 3. We concluded that simulation is a useful strategy to improve cognitive learning, and behavioural and practical competencies such as public speaking. As for the teaching method, although blended learning did not offer better results than traditional learning, it seems useful provide there is at least one face-to-face session so that the student can perform a speech and receive corrective feedback.     

Supporting nursing students with dyslexia in clinical practice

AIMS: To determine whether pre-registration nursing students with dyslexia experience specific problems in developing clinical competence, identify what strategies they use and how they may be supported in clinical practice. METHOD: Qualitative case study methodology was used. Stage 1 involved semi-structured interviews with seven students, three support and eight teaching staff, postal questionnaires from nine mentors, in addition to a review of policy documentation. Stage 2 involved a two-year study of four students on their branch programme and included semi-structured interviews with seven mentors. FINDINGS: The students' difficulties in clinical practice fell into three categories: dealing with information; performing the role; and administering drugs. Specific supporting measures included: informal and formal support networks; portable information technology equipment; and personal strategies, for example, rehearsing difficult tasks such as the handover report. The students' relationships with their mentors and the type of environment they were working in were key to the successful development of clinical competence. CONCLUSION: Nursing students who have dyslexia have specific learning difficulties in practice. Their response to these difficulties is individual and support needs to be tailored to meet their specific needs.     

Evaluation of a mentor-arranged clinical practice placement for student nurses

Second year nursing students evaluated a new initiative, the Mentor-Arranged Clinical Practice (MACP), which supplemented their other clinical experiences. Seventy-eight students (95.6%) returned their completed questionnaires. Results indicated that the MACP program was beneficial to the students in the acquisition of knowledge, improvement of basic nursing skills, time management, prioritisation in patient care, and improvement in their confidence and self-esteem. Students identified six positive aspects of the MACP program: continuity and consolidation of nursing skills, improved communication and reporting skills, working in a variety of shifts, and working as a team member. Characteristics of a good mentor encompassed four areas: personality traits, teaching ability, nursing competence and interpersonal relationship. Findings suggest that there is a need for the development of mentorship models in the clinical experiences of undergraduate nursing courses, and the importance of effective clinical teachers in preparing nursing students for the workforce.     

The perceptions of nursing students of practice-based teaching

The issue of students learning in practice has been an ongoing debate and link lecturers are increasingly expected to be involved in teaching in the practice setting. This is of particular relevance in light of current government and professional recommendations, which emphasise the importance of learning in practice settings in pre-registration programmes. This study aims to provide insights into the students' perceptions of practice-based teaching facilitated by link lecturers in pre-registration education. Focus group interviews were used as the method of data collection. The sample consisted of three focus groups of 4–14 students each. Three focus group interviews were conducted and data analysed to identify common themes. The following themes emerged from the result: integration of theory to practice, development of the skill of reflection, student support, peer support and shared learning and motivation. The future of practice-based teaching is discussed in relation to the enhancement of: integration of theory to practice, development of the skill of reflection and student support. Suggestions for the ways in which practice-based teaching could be facilitated are offered and these include having an educational structure which supports regular teaching sessions in practice settings and a strategy for staff development.