It is the end of the year and time to look back as well as forward to the new year!

There were two blogs that resonated with nurse educators in 2015 and had the most views. Both were related to strengthening student learning in the clinical setting.

As I look ahead to 2016, know that I will make clinical education a priority that will serve the needs of nurse educators as well as strengthen student transition from academia to clinical practice.

In today’s blog that originally appeared in February, there is a series of questions that must be asked to strengthen student’s critical thinking skills which will then improve their ability to clinically reason and make a correct clinical judgment.

This line of questions begins by asking the WHAT of all that a nurse does!

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Never Assume…

Asking questions of students is one of my favorite strategies to quickly and easily assess and evaluate their level of knowledge and understanding in the clinical setting.

When I was a new clinical adjunct and ICU nurse, I took it for granted that since students were currently in school, they would have a deep knowledge of pharmacology like I had once in practice.

As a critical care nurse, understanding the mechanism of action of the most common and important medications and IV drips used in this context is essential to the critical thinking and anticipation of the expected physiologic effects as well as most common side effects.

So as my first student that day confidently responded that the atenolol she was going to administer is a beta blocker and it was a safe dose to give, I innocently asked a simple question that I thought would be simple:

“What is a beta blocker blocking?”

She looked at me with a blank look and fear was clearly evident because she did not know the answer. I was confident that she knew the answer but I had to draw it out. So I asked, “is this medication blocking sympathetic or parasympathetic nervous system stimulation?”

“Sympathetic”

I responded, “if it is blocking sympathetic stimulation, knowing how fight or flight will impact heart rate and blood pressure, how will this medication affect your patient if it blocking this effect?”

She confidently responded, “It will lower heart rate and blood pressure.”

By using additional questions of a lower level of difficulty (content), the correct answer was drawn out, and her confidence in her ability remained intact though it took additional time.

What…?

What I learned from this exchange that has since been repeated numerous times as an educator is do NOT assume that just because a student can confidently state the pharmacologic classification of the drug, that this equals knowledge and understanding of the mechanism of action.

To test this hypothesis yourself, ask your students that following “what” questions in your next clinical …

• WHAT is a beta blocker blocking?
• WHAT is a calcium channel blocker blocking?
• WHAT is an ACE inhibitor inhibiting?

This level of understanding is essential because once the student can communicate this content in their OWN WORDS, and not simple parrot what is written in the drug handbook, they will be able to readily identify the clinical relationship between the physiologic effect and the most common side effects and nursing assessments that are required by the nurse WITHOUT looking them up in the drug handbook!

For example, once the mechanism of a beta blocker is clearly understood, it becomes obvious that the assessments that are needed by the nurse in order to be safe to administer are BP and HR and that the most common side effects are low HR and hypotension!

Additional ‘What’ Questions

Since medication administration is an essential responsibility of the professional nurse, the following are a series I ask my students of the most common medications that must be deeply understood:

• WHAT is the pharmacologic class?
• WHAT is the mechanism of action (in your own words)?
• WHAT is the expected patient response based on the mechanism of action?
• WHAT assessments do you need to know before you administer and then follow up afterward
• WHY is your patient receiving? (not a ‘what’ but to deepen nurse thinking its all about the ‘whats’ and the ‘whys’!)

When a student can verbalize this series of ‘what’ questions, they have clearly communicated that they have the foundational knowledge needed and are safe to administer.

‘What’ If?

This series of questions guides students to identify the most likely/worst possible complication. This is the first step to prepare students to ‘rescue’ if there is a change in status. In the clinical setting, faculty can use the most common complications to help develop this proactive nurse thinking skill. Expect students to not only identify the nursing assessments but also the interventions if any of these complications develop.

The following are examples of this line of questioning:
‘What if’ your patient…

• Develops chest pain?
• Develops a temp of 101?
• Drops BP to 90/50?
• Develops acute confusion on patient controlled analgesia?
• Develops rapid irregular heart rate of 140?
• Develops sudden onset of shortness of breath

‘What” and Priority Setting

Two questions on my template of 12 clinical reasoning questions (FREE download) that break down the essence of clinical reasoning to practice also begin with ‘what’ and emphasize the importance of identifying correct priorities.

• WHAT nursing priority captures the “essence” of your patient’s current status and will guide your plan of care?
• WHAT educational priorities have you identified and how will you address them?

In Closing

Remember that the primary objective of the clinical educator is NOT about the tasks and how many procedures and medications you can administer (I too have made this my barometer of a successful clinical in the past!). But it is all about developing the THINKING of each student and providing opportunities to APPLY knowledge in the clinical setting and strengthen their ability to think like a nurse!

By using these and other questions that accomplish this same objective, though you will be remembered as difficult and tough, you will have your students thank you after they graduate because they will appreciate that you were the one who prepared them well for real world clinical practice!

Comment Question:
What questions do you consistently utilize in the clinical setting to strengthen the thinking of your students?
Comment below and let the conversation begin!

Personal Note from Keith

Today is a special as well as sacred time of year. As you reflect on the significance of Christmas, Mathew 1:23 captures the essence of the season beautifully:

“Behold, the virgin shall conceive and bear a son,and they shall call his name Immanuel”(which means, God with us).

God chose to reveal Himself through the birth and life of Jesus, but through his death on the cross came to rescue you from the consequence of your sin (Romans 3:23) to make it possible for you to be renewed, restored and transformed! This is good news and is a source of hope and peace in a troubled world.

If you would like to know why the gospel is called “good news” I hope you’ll download the booklet For Your Joy