For any student pursuing a nursing degree, the clinical rotations are where you really earn your pin.
“In clinical studies you put into practice what you learn in theory,” says José Blanco, MSN, MEd, RN, instructor in clinical nursing and director of the RN-to-BSN program at the University of Texas at El Paso School of Nursing. “The most important outcome is that you demonstrate that you know nursing—[which means] not only knowing the disease processes but also identifying signs, symptoms and treatments.”
There’s no denying that performing well in clinicals is a major challenge for just about any nursing student. But for minority students—including male students, as well as students of color—success in the clinical rotation often is linked to faculty members’ sensitivity to issues these students face that may differ from what non-minority students experience. It also can depend on adapting teaching strategies to diverse learning styles, advocating for students who encounter bias in the clinical setting, and creating effective interventions for students who run into obstacles or need to improve their performance.
The process begins with making sure students fully understand what they are expected to accomplish. While the overall objective of clinical studies is for the student to demonstrate competency in providing safe nursing care to patients, each clinical rotation has a different set of objectives, determined by the related course and the academic level of the student, says Emilia Frederick, MSN, RN, clinical instructor in the Department of Nursing at North Carolina Central University, a historically black university in Durham, N.C.
“The objectives students need to accomplish in a clinical rotation in their first semester as a nursing student are very different than the objectives students have to accomplish in their senior year,” she emphasizes.
Blanco notes that clinical students must learn to master a wide range of subject areas: pharmacology, I.V. therapy, transfer and discharge procedures, error and injury prevention, emergency response plans, safe use of equipment, infection control and patient rights. They also need to understand how to manage care and be an advocate for the patient, he says.
In addition, Frederick says, students must also become familiar with the particular standards and practices of the health care facility and unit where they are training—from the method of dispensing medication to the policies for interacting with patients’ family members.
One way instructors can help eliminate barriers to success in clinicals is to recognize different learning styles among students from diverse backgrounds.
“Many minority students, when we actually assess their learning styles, come across typically as sensory learners, as opposed to being analytical learners,” Frederick says.
Sensory learners need to have their senses engaged in the learning process, she explains. “If they don’t see it, hear it or touch it, it takes a long time for them to assimilate the information and be able to analyze it and apply it to the patient. If someone is an analytical learner, you can give them the information right out of the book and they are able to process it.”
While some studies suggest that sensory learners are especially prevalent among African Americans and other ethnic minority populations, Frederick argues that this learning style is not exclusive to those groups.
“We also have a generation of students who are from the computer age,” says Frederick, whose school has incorporated everything from simulation to YouTube videos and MP3 players to capture the attention of such students. “Sensory input is all that you get in the high-tech environment we’re living in today, so learning is really [becoming] more geared to sensory stimulation.”
Instructors also need to be aware that for some Hispanic students, cultural and language differences make the clinical rotation especially challenging, says Blanco, whose nursing school serves a large number of ESL (English as a second language) students. An even bigger obstacle for many of these students is time management. In addition to their nursing studies, many Hispanic students also have demanding family obligations, and they are also more likely to be working while going to school. At the University of Texas at El Paso School of Nursing, which has an 80% Hispanic student population, 75% of the students work, Blanco says.
Perhaps no other success strategy is as important as making sure minority students are thoroughly prepared before they receive their clinical assignments. At North Carolina Central University, a pre-clinicals skills lab introduces students to the basic skill sets in which they will have to demonstrate competence. They also must pass a medication documentation exam before being allowed to mix and dispense medications to patients. Before each patient assignment, which comes with a 24-hour notice, the student must review the patient’s medical history and prepare a care management plan.
“It’s important to clearly communicate the goals and expectations for students, and to be consistent with those expectations,” Frederick says. “It gets crazy when there’s inconsistency, or it’s constantly evolving. That creates a recipe for disaster.”
Ensuring that students get off to a good start can even involve something as simple as addressing transportation issues, according to Norma Martinez-Rogers, PhD, RN, FAAN, president of the National Association of Hispanic Nurses (NAHN) and associate professor/clinical instructor at the University of Texas Health Science Center at San Antonio (UTHSCSA) School of Nursing. “We have programs [at our school] that help students find ways to get to clinical sites,” she says. “We highly encourage carpooling.”
Advance preparation is especially critical for male nursing students entering the OB/GYN and pediatrics rotations. At the University of Portland (Ore.) School of Nursing, all students complete a skills lab before entering these rotations. But clinical instructor Kathleen Bell, MSN, RN, CSN, says, “The people who get the most out of it tend to be the male students. They like having an opportunity to role play. They like being able to practice on a doll how to diaper a baby, how to wrap the baby appropriately and how to hand the baby to the parents, because they may not have had real-life experience doing that. We also have patient simulation equipment available so that male students can practice performing a breast examination on the models. They can be shown how to use the peri-packs before they are in a situation where they have to do this with real people.”
The skills lab also devotes significant time to teaching labor support—“the old-fashioned things like rubbing backs, warm showers, foot massages [and generally] being able to help women cope with labor in ways that don’t involve the use of pharmacology,” Bell says.
To help allay male students’ fears that female patients might accuse them of sexually inappropriate touching, two other faculty members at the University of Portland School of Nursing have developed a video called “Intimate Touch for Males.” It explains the need for male nurses to approach sensitive OB examinations differently than female nurses—for example, “being aware of other females in the room and always doing a neutral touch before engaging in a very sensitive touch,” Bell says.
“We give [male students going into OB/GYN rotations] extra attention and time, because this is a particularly sensitive area and it may be difficult for them,” adds Bell, who asks for male students to be assigned to her courses because of her experience in helping them overcome gender-based barriers. “That being said, I find that the male students love OB, and they are always surprised. They expect that it’s going to be terrible, that they’re going to want to run screaming down the hall in the other direction—and they don’t.”
Another key practice at the University of Portland is to have instructors on the hospital site during students’ OB and pediatric rotations. “This is not our model in every other clinical setting,” Bell explains. “But because this is delicate information and just a big crisis time for families, we believe it’s very important to have the instructor there on site. It makes a big difference for students who come from a different culture or whose primary language is not English, and it’s certainly helpful for the male students.”
Unfortunately, there may be times when minority students encounter racial, cultural or gender bias in their clinical assignments, such as racist remarks from a patient or disparaging comments about male nurses from female RN staff on the unit. In the workshops Frederick conducts with nursing faculty from various schools, she tells them that part of their job is “to protect your students.”
“You have to know when you need to step in front of the firing line, so to speak, because there are certain things a student should not be exposed to as an entry-level student in nursing,” she maintains. “They haven’t learned the socialization completely yet. They are still getting their feet wet. If you don’t protect them, it can be quite a problem.”
Playing that protector role might mean talking with the unit staff about avoiding assigning problematic patients to students who are too inexperienced to handle them, Frederick says. She admits that it’s a delicate balancing act. “You have to be able to select the right patients to match the academic standing of the student but still give him or her a very realistic patient population to work with.”
Blanco stresses that nursing students must be trained to render competent care no matter what the patient’s attitude might be. “The student has to understand: You are not there to value-judge,” he says. “You are not there to stereotype. You are not there to share your values with the patient or give advice to the patient. You need to be an advocate of the patient.”
Martinez-Rogers concurs. “Unfortunately, students are not there to change the opinion of whoever they’re dealing with. They have to remain focused and stick with their goal. If [the problem] gets really bad, we advise students to go to [the faculty member] who is in charge of their course.” If a student does bring a legitimate grievance to the faculty, she adds, “we’ll support them.”
In Bell’s view, “skill and caring [transcend] cultures and genders.” Still, she concedes, even though male nurses have become a familiar sight in many hospital units, gender does make a difference for some patients, especially in the OB/GYN setting. Bell’s practice is to give OB patients the option to reject any nurse they don’t feel comfortable with, for whatever reason.
What can instructors do to help minority students who are not doing well in their clinicals improve their performance? When and how should you intervene?
When faculty members see that a student is not performing well, says Frederick, “they need to intervene as quickly and as early as possible.” She tells her workshop groups to follow their gut feelings. When they sense that students are in trouble, it’s time to start observing them more closely and discussing their concerns.
Objectivity is paramount when evaluating student performance. “It cannot be based on personalities or on whether or not you like them,” Frederick says.
She recommends documenting the student’s deficiencies in writing, as well as each conversation with the student about how to resolve the issues.
“Students can be emotionally charged during these discussions, and they don’t always hear everything that you are telling them,” she explains. “You need to document [what was said] and have a witness.” She suggests bringing the student’s advisor in on the discussion.
Martinez-Rogers adds: “I think the faculty has a moral obligation the minute they suspect that a student is having a problem to work with that student one-to-one and refer the student to [sources for] help.”
That intervention might take the form of a tutoring or mentoring program, like the one at UTHSCSA School of Nursing that pairs undergraduates with graduate nursing students. Nursing schools typically offer a variety of resources to help students succeed. The challenge, according to Martinez-Rogers, “is trying to get [students] to learn that it’s OK to ask for help.”
In the Spring 2009 semester, Bell began teaching what she says is a unique course at the University of Portland, in which nursing students develop their own study plans in preparation for professional licensure. Students in the class review their performances on standardized tests, such as those administered by the Assessment Technology Institute.
“They get a report of the areas in which they are deficient,” Bell says. “It can be critical thinking. It can be leadership. It can be patient safety.” By observing patterns in their test results, the students are able to design a “care plan” for improving their own performance.
Having nursing instructors on site during clinical rotations is a major advantage, Bell adds, because they can assist in identifying ways to address a problem immediately. “It’s not one of those things [that should be] left to the nurse on the unit.”
To be effective, intervention must be both constructive and timely, Martinez-Rogers advises. “It doesn’t work to tell students they did [something] wrong if you don’t help them to find a solution,” she says. “[You shouldn’t be] telling students at mid term, ‘you are failing clinicals.’ It’s a little late.”
For any student, a nursing education requires a major investment of time, effort and, in many cases, money—and for minority nursing students, the sacrifices are sometimes even more significant. That’s why Martinez-Rogers believes that preparing minority students for success in clinicals—and other steps toward receiving their diplomas—is so important.
“These students work hard,” she says. “They spend a lot of money on their [tuition and] books. And none of them come to nursing school to fail.”