I quickly learned as a new clinical educator that students will take as long as you give them to gather data and prepare to care for their patient in clinical.
Give them one hour, and they will spend all 60 minutes combing the chart to make sure they did not miss anything. Give them more time and they will do the same!
The reason for this observation?
As novice nurses, students see all classroom content and clinical data as equally relevant (Benner, 1982).
In order to best prepare students for practice after the NCLEX®, they need to be guided to identify what clinical data is RELEVANT and what aspects of the medical record are most important to be reviewed to ensure that they are well prepared and safe.
Using my lens of current clinical practice in acute care, I will share a practical approach to quickly and concisely review the medical record so students can be confident they are well prepared to assume care even when responsible for multiple patients.
How to Quickly Prepare
Though 1-2 patients is a typical patient assignment in nursing school, depending on the practice setting, students will be responsible for the care of 4-6 patients in acute care and even more in transitional or skilled care settings.
The nurse must first know the “big picture” or the essence of the primary problem and what brought the patient to the clinical setting. Once the bigger picture is clearly understood, then the nurse can focus on specific clinical data that will help put the current picture in context.
Electronic medical records (EMRs) are becoming the standard for reviewing and documenting in acute care. But these principles will also work for paper charts.
Just as you want to have a systematic approach to giving report, you want to have a similar consistent approach to collecting clinical data.
To make sense and bring order to your data collection, you need to have something to write this information on.
That is why you must create your own patient preparation worksheet. In order to quickly and efficiently identify relevant clinical data from the medical record and time map your clinical day, a well-designed patient preparation worksheet can help facilitate the collection of clinical data with multiple patients.
Big Picture Clinical Data
In order to quickly identify the big picture of the patient story, this essential data collection has already been done for you by the primary care provider in the admitting history and physical (H&P) and/or the primary care provider’s most recent progress note.
This is the FIRST place the nurse must go to in the medical record and note what is most relevant to visualize the big picture. The nurse can quickly gather the following data and note it on the patient preparation worksheet.
Primary Care Provider’s Progress Note
- Patient name, age, primary medical problem, day of admission
- RELEVANT past medical history that is related to primary medical problem. The patient may have ten medical problems, but I want to know about the one or two that are influencing the current problem.
- Concise summary of this admission and any problems as well as progress towards the current plan of care from the physician’s perspective.
Specific Clinical Data
Once the big picture or essence of the current clinical situation is identified, RELEVANT specific clinical data will begin to make sense and make it possible to put the clinical puzzle together.
Use the following sections of the chart or EMR to access and note the following essential clinical data.
Remember the foundational principle of clinical reasoning that emphasizes RELEVANCE. Identify the specific lab values that are most important, based on your knowledge of the primary problem.
TREND these most important lab values, even if they are normal, because they have clinical significance and note the direction of the trended labs. Determine if they are improving or reflect a possible problem.
It is especially important to do this with the most recent lab values and those that were collected on your shift.
Medication Administration Record (MAR)
What prn medications were given in the past shift? Clarify with the nurse in report what prn medications are working and what needs to be done differently based on evaluation (pain meds/pain control, etc.)
Focus on kardex data that includes code status, contact precautions, primary physician/group, location of IVs and any infusions, new orders, activity, labs to be drawn on next shift.
Vital Sign Flowsheet
Note and write down the last set of vital signs and any clinical trends that may be significant over the last shift. Identify patient ambiguity for vital signs that may be outside textbook norms.
Intake and Output (I&O)
Note I&O if relevant by documenting the output over the last 8/24 hours and trend of daily weights.
Highlight head-to-toe nursing assessment with data that includes an emphasis on the most relevant body system based on primary problem as well as abnormal assessment findings. Identify patient ambiguity for vital signs that may be outside textbook norms.
Once this clinical data is assimilated, you will begin to get a sense of the nursing priorities for your patient. Begin to formulate these priorities and when you obtain a nurse-to-nurse report, you will be able to clarify your thoughts as needed with the prior nurse. Once the essence of the current nursing priority is identified, the plan of care follows with resultant interventions and outcomes that will advance the plan of care on your shift.
Though students require more time to complete clinical prep, clinical educators need to prepare and guide students to become more proficient in collecting clinical data for each patient they care for.
Just like a runner clocks his time to see if improvement is being made in his speed , do the same with students as they data collect, especially those who are in the final year/semester.
Have students time their data collection and see if they can shave off minutes off their “times” as the clinical progresses knowing that this will be needed to prepare them for practice.
Reality shock faces nursing students who are about to graduate. The essence of reality shock is when students enter the nursing profession but recognize that they are unprepared for real world practice realities.
As a result, many new graduate nurses leave the profession in the first year (Clark & Springer, 2012).
Don’t let your students become a casualty of burnout and reality shock!
Do all that is needed including guiding students to streamline clinical prep and paperwork and give them guidance to streamline data collection so they will be well prepared and safe as they enter professional practice.
What do you think?
What strategies have you found effective to better prepare students for practice after the NCLEX®?
Comment below and let the conversation begin!
RELEVANT Past Blogs
- Questions That Every Student Must Be Asked in Clinical to THINK Like a Nurse
- How to Effectively Teach Clinical Reasoning So Students Can THINK More Like a Nurse
- Six Clinical Relationships Students Must Recognize to THINK More Like a Nurse
- Benner, P. (1982). From novice to expert. American Journal of Nursing, 82(3), 402–407.
- Clark, C.M., & Springer, P.J. (2012). Nurse residents’ firsthand accounts on transition to practice. Nursing Outlook, 60(4), E2-E8.
Keith Rischer – Ph.D., RN, CCRN, CEN
As a nurse with over 35 years of experience who remained in practice as an educator, I’ve witnessed the gap between how nursing is taught and how it is practiced, and I decided to do something about it! Read more…
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