Feedback: An essential element of student learning in clinical practice

Aims and objectives.  The aim of this literature review, set within an Irish context, is to present a broad overview of former and existing clinical support personnel, explore the concept of facilitation and examine what is known about the role of the clinical education facilitator.

Background.  The importance of providing a supportive clinical environment to enhance clinical teaching and learning is strongly portrayed in the literature. While the past two decades have borne witness to various clinical support personnel, the literature identifies conflicting demands that these personnel face. No suggestions are advanced as to how to overcome these difficulties, which inevitably influence the quality and quantity of their clinical teaching role. An identifiable gap exists over who has prime responsibility for clinical teaching. It is timely that alternative possibilities for organizing clinical teaching are investigated. A new post emerging in practice settings is that of the clinical education facilitator who is meant to be the key linchpin in clinical areas for reducing the theory–practice gap.

Method.  Relevant literature for this review was sourced using the computerized databases CINAHL, Medline and Synergy. Manual searching of relevant nursing journals and sourcing of secondary references extended the search. Government reports and other relevant documents were obtained through pertinent websites.

Results.  Papers that explicitly examined the concept of facilitation and explored the posts of clinical education facilitators were included; six research papers were accessed and reviewed. In addition seven non-empirical papers were included.

Conclusions.  It is clear that considerable lack of role clarity resides over what constitutes clinical facilitation and the role of the clinical facilitator. Thus, it is paramount to strengthen this support role with Irish empirical evidence.

Relevance to clinical practice.  A major advantage in having a ward-based clinical education facilitator is the benefit of having access to someone who can concentrate solely on clinical education and support with attempts to narrow the theory–practice divide.

Clinical education facilitators: a literature review

The traditional hospital-based model of cardiac rehabilitation faces substantial challenges, such as cost and accessibility. These challenges have led to the development of alternative models of cardiac rehabilitation in recent years. The aim of this study was to identify and critique evidence for the effectiveness of these alternative models. A total of 22 databases were searched to identify quantitative studies or systematic reviews of quantitative studies regarding the effectiveness of alternative models of cardiac rehabilitation. Included studies were appraised using a Critical Appraisal Skills Programme tool and the National Health and Medical Research Council's designations for Level of Evidence. The 83 included articles described interventions in the following broad categories of alternative models of care: multifactorial individualized telehealth, internet based, telehealth focused on exercise, telehealth focused on recovery, community- or home-based, and complementary therapies. Multifactorial individualized telehealth and community- or home-based cardiac rehabilitation are effective alternative models of cardiac rehabilitation, as they have produced similar reductions in cardiovascular disease risk factors compared with hospital-based programmes. While further research is required to address the paucity of data available regarding the effectiveness of alternative models of cardiac rehabilitation in rural, remote, and culturally and linguistically diverse populations, our review indicates there is no need to rely on hospital-based strategies alone to deliver effective cardiac rehabilitation. Local healthcare systems should strive to integrate alternative models of cardiac rehabilitation, such as brief telehealth interventions tailored to individual's risk factor profiles as well as community- or home-based programmes, in order to ensure there are choices available for patients that best fit their needs, risk factor profile, and preferences.

Alternative models of cardiac rehabilitation: a systematic review

Objectives To evaluate the relative effectiveness and cost-effectiveness of a home-based programme of cardiac rehabilitation using the Heart Manual, with centre-based programmes. It also sought to explore the reasons for non-adherence to cardiac rehabilitation programmes. Design An individually randomised trial, with minimisation for age, gender, ethnicity, initial diagnosis and hospital of recruitment. Participants were followed up after 6, 12 and 24 months by questionnaire and clinical assessment. Individual semistructured interviews were undertaken in the homes of a purposive sample of patients who did not adhere to their allocated programme, and focus groups were undertaken with groups of patients who adhered to the programmes. Setting Four hospitals in predominantly inner-city, multi-ethnic, socio-economically deprived areas of the West Midlands in England, for 2 years from 1 February 2002. Participants A total of 525 patients who had experienced a myocardial infarction (MI) or coronary revascularisation within the previous 12 weeks. Interventions All the rehabilitation programmes included exercise, relaxation, education and lifestyle counselling. All patients were seen by a cardiac rehabilitation nurse prior to hospital discharge and provided with information about their condition and counselling about risk factor modification. The four centre-based programmes varied in length from nine sessions at weekly intervals of education, relaxation and circuit training to 24 individualised sessions over 12 weeks of mainly walking, fixed cycling and rowing with group-based education. The home-based programme consisted of an appropriate version of the Heart Manual, home visits and telephone contact. The Heart Manual was introduced to patients on an individual basis, either in hospital or on a home visit. Home visits by a nurse took place at approximately 1, 6 and 12 weeks after recruitment, with a telephone call at 3 weeks. At the final visit, patients were encouraged to maintain their lifestyle changes and to continue with their exercise programme. Where needed, follow-up was made by a rehabilitation nurse who spoke Punjabi. An audiotape of an abridged version of the Heart Manual in Punjabi accompanied the manual for patients with a limited command of English. Main outcome measures Primary outcomes were smoking cessation, blood pressure, total and high-density lipoprotein cholesterol, exercise capacity measured by the incremental shuttle walking test and psychological status measured by the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes included self-reported diet, physical activity, cardiac symptoms and quality of life. Health service resource use and costs of rehabilitation programmes from health service and societal perspectives were also measured. Adherence to the physical activity element of the rehabilitation programmes was measured by questionnaire 6, 9 and 12 weeks. Results No clinically or statistically significant differences were found in any of the primary or secondary outcome measures between the home- and centre-based groups. Significant improvements in total cholesterol, smoking prevalence, the HADS anxiety score, self-reported physical activity and diet were seen in both arms between baseline and the 6-month follow-up. Five or more contacts with a cardiac rehabilitation nurse were received by 96% of home-based participants, whereas only 56% of centre-based participants attended this many rehabilitation classes. The direct rehabilitation costs to the health service were significantly higher for the home-based programme (mean cost 198 pounds versus 157 pounds for the centre-based programme), but when patient costs were included the mean cost of the centre-based arm rose to 182 pounds. Patients' reasons for not taking up or adhering to cardiac rehabilitation were multifactorial and very individual. Other health problems limited some patients' ability to exercise. Most non-adherers found some aspects of their cardiac rehabilitation programme helpful. Many had adapted advice on rehabilitation and were continuing to exercise in other ways and had made lifestyle changes, particularly to their diet. The home-based patients' lack of motivation to exercise on their own at home was a major factor in non-adherence. The focus groups revealed little diversity of views among patients from each programme. Patients in the hospital programme enjoyed the camaraderie of group exercise and the home-based patients valued the wealth of information and advice in the Heart Manual. Conclusions A home-based cardiac rehabilitation programme for low- to moderate-risk patients does not produce inferior outcomes compared with the traditional centre-based programmes. With the level of home visiting in this trial, the home-based programme was more costly to the health service, but with the difference in costs borne by patients attending centre-based programmes. Different reasons were given by home and hospital cardiac rehabilitation patients for not taking up or adhering to cardiac rehabilitation, with home-based patients often citing a lack of motivation to exercise at home. Social characteristics, individual patient needs and the location of cardiac rehabilitation programmes need to be taken into account in programme design to maximise participation. Research is recommended into cardiac rehabilitation in patients from ethnic minority groups; measurement tools to assess physical activity and dietary change; evaluating the Heart Manual in patients who decline centre-based cardiac rehabilitation; the implementation of home-based programmes in the UK; and strategies that sustain physical activity in the long term.

The Birmingham Rehabilitation Uptake Maximisation Study (BRUM). Home-based compared with hospital-based cardiac rehabilitation in a multi-ethnic population: cost-effectiveness and patient adherence.

Future challenges for nursing education--a European perspective.

Background . This study is a replication of research undertaken by Mogan and Knox in 1987, which investigated and described characteristics of ‘best’ and ‘worst’ clinical educators. They developed and used an instrument known as the Nursing Clinical Teacher Effectiveness Inventory (NCTEI), a 48 item checklist that describes discrete characteristics clustered into five subscales or categories: teaching ability; interpersonal relationships, personality traits, nursing competence and evaluation. The tool has since been used in several countries including Greece, Hong Kong, Israel and North America and is the instrument most frequently used to identify effective clinical teaching characteristics of clinical educators.

Aim . The aim of the present study was to administer the NCTEI to undergraduate nursing students and clinical educators in a school of nursing at an Australian university to explore the perceived characteristics of effective clinical educators as rated by students and educators, and the significant differences and commonalities between these perceptions.

Findings . Results indicate that the category of Interpersonal Relationships was the most highly valued characteristic rated by both Australian students and clinical educators, and both groups (students and educators) ranked the subset of personality as the lowest amongst five categories. In common with Mogan and Knox, this study found that students who had not been exposed to real clinical situations prior to commencing nursing studies ranked items related to interpersonal relationships more highly than students who had previous nursing experience. Although there were no statistically significant differences in the two groups, students were more concerned with evaluation while clinical educators were more concerned with nursing competence.

Conclusion.  This study is the first research to be reported in Australia, which has simultaneously compared both students' and educators' perceptions and the first to replicateMogan and Knox's seminal work. Findings point to the need forclinicaleducators tovalue interpersonal relationships with students as well as clinical competence.

Nursing students' and clinical educators' perceptions of characteristics of effective clinical educators in an Australian university school of nursing

Effectiveness of home-based cardiac rehabilitation for special needs patients Background. The benefits of cardiac rehabilitation programmes have been well documented including reductions in mortality, improved physical performance, and improved quality of life. However, a large number of special needs patients often fail to access these programmes. Of particular concern are elderly patients with chronic illness and disability. Aims. To evaluate the effectiveness of a home-based cardiac rehabilitation programme in improving health outcomes and rehabilitation access for special-needs patients. Design. Using a one-group pre and post-test quasi-experimental design 40 elderly patients recently discharged from hospital following a cardiac event completed the Short Form Health Survey, the Angina Quiz, and the Exercise Assessment Questionnaire prior to undertaking home-based rehabilitation. The rehabilitation programme consisted of four community nursing contacts over a 9-week period primarily aimed at individual patient education and carer support. Analysis. Descriptive statistics provided analysis for demographic data. Repeated measures multivariate analysis of variance (MANOVA) were computed to examine changes in health-state and practices. Results. Significant positive changes were found for measures of quality of life, knowledge of angina, and exercise tolerance. Additionally, the higher levels of participation and completion by older women was encouraging. Development of carer competence through an improved knowledge base and nursing support was also evident. Limitations. While theoretically defensible positive outcomes were found these results need to he replicated in a larger study. Similarly, the limitations imposed by a single group pretest, post-test design suggest that claims of generalizablity need to be limited to the specific variables measured in this study. Conclusion. The study demonstrated medium term positive health outcomes. These positive findings suggest that home-based rehabilitation using larger samples of older patients with comorbidities, and using randomized comparative group designs, may he a fruitful area in future research.

Effectiveness of home‐based cardiac rehabilitation for special needs patients

An 8-month pilot study conducted in urban, rural and remote areas of Australia sought to identify barriers to nurse-consumer partnerships, as well as strategies to overcome these barriers. One hundred and ninety-nine Registered Nurses (RNs) and 36 consumers participated across 14 workshops to collect data for the pilot study. Analysis of these data found that nurses' perceptions of partnership with consumers were diverse. Nevertheless, participants in the workshops identified 'communication' as the principal barrier to nurse-consumer partnerships. Contexts in which communication barriers occur grouped easily under the themes of information transfer, documentation, education, personal and interpersonal situations, guidelines and policy, organizational structures, politics, resources and time. Workshop participants also worked together to identify/recommend strategies through which the most important barriers to communication in nurse-consumer partnerships could be addressed.

Communication: principal barrier to nurse-consumer partnerships.

This paper reports on a study investigating the relationship of nursing students' approaches to learning and processing of information, science content knowledge, ability in interpreting and organizing clinical data (nursing assessment), and logical reasoning ability with the accuracy and quality of the nursing diagnosis made in a simulated diagnostic reasoning task. One hundred and sixty-nine second-year pre-service nursing students participated in the study. Results of path analyses indicated a set of pathways from surface approach to low-quality nursing diagnosis that reflected less competent diagnostic reasoning; and a second set from deep/achieving approach through content knowledge and logical reasoning to higher-quality nursing diagnosis that reflected more competent diagnostic reasoning. The implications of these findings for nurse education are discussed.

Diagnostic reasoning among second‐year nursing students

Rationale, aims and objectives  The assumption that the acquisition and mastery of the nursing process alone is sufficient to explain problem-solving performance has been challenged in recent literature. Researchers have argued that the quality of prior knowledge is a key component in explaining performance. In addition, motivational orientation and the quality of reasoning have been found to have different effects on performance in cognitive tasks. The aim of this study is to explore student nurses’ clinical problem solving based on a model consisting of their motivational orientation, prior knowledge, diagnostic reasoning and diagnostic solutions.



Methods  One hundred and thirty-five second-year nursing students completed the Study Process Questionnaire and the Causal Attribution Questionnaire prior to receiving five lectures on mental illness. A knowledge test and a clinical problem-solving task provided measures of prior knowledge, quality of diagnostic reasoning, and the quality and comprehensiveness of nursing diagnosis. A correlational design using pairwise correlations, hierarchical regression and path analysis examined the relationships among these data.



Results and conclusions  The results indicated an important role for a belief in personal control, for the accessibility and structuring of prior knowledge, and the quality of diagnostic reasoning, in generating high quality and comprehensive nursing diagnoses. The findings suggest that all contributing components of clinical problem solving need to be addressed in nursing education.

Krystyna Cholowski

Papers

Nursing students' and clinical educators' perceptions of characteristics of effective clinical educators in an Australian university school of nursing

Effectiveness of home‐based cardiac rehabilitation for special needs patients

Communication: principal barrier to nurse-consumer partnerships.

Diagnostic reasoning among second‐year nursing students

Cognitive factors in student nurses' clinical problem solving.