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Is it Time to Rethink How We Teach Students in Clinical?

By March 1, 2023No Comments

The Problem

The traditional clinical apprenticeship model with a clinical educator working with a group of students in the practice setting has been used to teach nursing students for over 50 years. But did you know that it has no evidence to support its effectiveness?

The clinical apprenticeship model has not been tested rigorously to determine if it produces nurses who are prepared for clinical practice (Leighton et al., 2021).


Health care and the complexity of patient care have changed dramatically over the past 50 years. The current scope of nursing practice relies on higher-order clinical judgment skills to provide safe patient care for complex patients that may not be adequately developed in the traditional clinical apprenticeship model.

Could the traditional apprenticeship model contribute to the declining percentage of nurses meeting entry-level expectations of clinical judgment? Nurses who possess entry-level clinical judgment have declined from 35% in 2005 (del Bueno, 2005) to 23% in 2017 (Kavanaugh & Szweda, 2017), and only 9% in 2021 (Kavanaugh & Sharpnack, 2021)!

In the article, Traditional Clinical Outcomes in Prelicensure Nursing Education: An Empty Systematic Review (2021), not one study was found to validate the learning outcomes of the traditional clinical model of 8-10 students mentored by a clinical educator.

Instead of quantitative data to determine the effectiveness of clinical teaching models, the 118 articles that met inclusion criteria for review were self-reports of student perceptions of learning or self-confidence. Research has shown that self-report of confidence does not match actual competence (Leighton et al., 2021).

The results of this empty systematic review are a wake-up call to nursing education. How much longer are we going to wait to produce higher-quality studies? The time is now.


Is there a relationship between the absence of studies to support clinical education best practices and the alarming decline in the percentage of graduate nurses prepared for clinical practice?

Contributing Factors

Current limitations of the existing clinical apprenticeship model include the following (Leighton et al., 2021):

  • Limited amount of quality time with faculty to promote learning
  • Random learning for students
  • Focus on supervising skills instead of emphasizing deep learning of knowledge to make informed clinical judgments
  • Faculty who are not adequately prepared to teach clinical using best practices
  • No established standard of training faculty compounded with educators who have no education preparation (nurse practitioner, etc.)
  • Assessment/evaluation of student performance includes scales/rubrics that may not have been tested for reliability/validity
  • Low bar or performance pass/fail, while a higher bar of performance is expected in classroom theory
  • Student assessment is prone to subjective bias and inconsistency between other clinical faculty

Which of these limitations of clinical teaching are present in your clinical or program?

Numerous strategies can be implemented to bring needed change to improve the practice readiness of graduate nurses (Leighton et al., 2021).


  • Focus less on actual clinical hours and more on the expected performance of essential clinical judgment skills and professional behavior.
  • Standardize the clinical experience, so students receive comparable clinical education.
  • Increase use of high-fidelity simulations to ensure that specific competencies and skills are practiced and evaluated.
  • Establish consistent standards for expected outcomes and competencies, then provide opportunities to meet these outcomes.
  • Use valid and reliable tools to evaluate outcomes and competencies, including adapting Lasater’s Clinical Judgment Rubric (LCJR) to evaluate clinical judgment skills.

There is a two-way ebb and flow strategy to strengthen clinical education in your program.

  1. Clinical faculty must bring essential knowledge taught in the classroom to clinical so that it can be applied to the bedside.
  2. Classroom faculty must continue to bring clinical to class and make learning active using case studies that practice and develop clinical judgment (Benner et al. 2010).

Post Conference Strategies

Faculty can use additional strategies to improve clinical education to maximize post-conference by using principles of debriefing that include reflection on clinical judgments made and what was learned to apply to future patient care. Educators can also use concise case studies relevant to the practice setting to standardize clinical learning by practicing and developing clinical judgment.


What can you do or have already done to implement strategies to bring needed change to improve practice readiness?


In the all-access faculty membership Think Like a Nurse, there are dozens of student handouts, clinical paperwork to standardize student learning, almost 100 clinical reasoning case studies topics, and much more that provide a comprehensive strategy to strengthen student learning.

Individual faculty can obtain access, but the best value is a discounted department membership. Receive a no-obligation quote.

Closing Thoughts

Compared to the medical profession, which has over 2500 years of history, nursing is in its professional infancy, going back only 175 years since the dawn of the modern era initiated by Florence Nightingale.

The body of research-based knowledge essential to advance nursing education is also in its infancy. The two primary peer-reviewed nursing research journals were established recently—The Journal of Nursing Research in the 1950s and the Journal of Nursing Education in 1962.

Be a Part of the Solution

You can help change this picture by pursuing your nursing doctorate or using your current doctorate to create needed knowledge by implementing research to provide evidence to support best practices to improve how nursing is taught in the clinical and classroom settings.

It is easy to view the dissertation process in doctoral education as only being about you, getting your terminal degree, and the benefits it provides. However, the bigger picture also needs to be considered: how you can influence the future of our profession through your dissertation and additional research to conduct after you graduate.

If you already have your doctorate, continue to use your education and practice experience to measure the impact that different, creative teaching approaches have on student outcomes. Just as Dr. Patricia Benner and Dr. Chris Tanner have impacted our generation with their legacy of scholarly work to improve how we teach nursing, if we have our doctorate, we should continue to prioritize research to provide the evidence to strengthen how nursing is taught to improve practice readiness.

Who will be the next nurse researcher in this generation to rise up and impact nursing education through their research? Why not you?


Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.

del Bueno, D. (2005). A crisis in critical thinking. Nurse Education Perspectives, 26(5), 278-282.

Kavanagh, J. & Szweda, J. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses’ clinical reasoning. Nursing Education Perspectives 38(2), 57-62.

Kavanagh, J.M., Sharpnack, P.A., (January 31, 2021) “Crisis in Competency: A Defining Moment in Nursing Education” OJIN: The Online Journal of Issues in Nursing Vol. 26, No. 1, Manuscript 2.

Leighton, K., Kardong-Edgren, S., McNelis, A. M., Foisy-Doll, C., & Sullo, E. (2021). Traditional Clinical Outcomes in Prelicensure Nursing Education: An Empty Systematic Review. The Journal of nursing education60(3), 136–142.

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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