Appreciating work complexity in beginning nursing clinical courses
Throughout this module we have been focusing on understanding the complexity of
nursing work. This focus is based on the assumption that the major barrier to making
progress in safety and quality is our failure to appreciate the complexity of the work for
which we are preparing students. Just how DO we prepare students for complex work
environments?
Conventional pedagogy is ubiquitous in nursing education. Using this pedagogy,
nursing educators focus on cognitive gain and skill acquisition beginning with simple
knowledge and skills and progressing to those considered to be complex (see Ironside,
2001 for a more detailed discussion of conventional pedagogy). In beginning clinical
courses, this means that students commonly are asked to provide basic care (i.e.:
bathing, oral care, feeding, positioning and transferring) to a single patient in a nonacute situation. As students progress through the curriculum, they take on additional
skills and responsibilities for patient care, more complex patients, and sometimes more
than one patient at a time.
Calls for improvement of the quality and safety of nursing care are now challenging
nursing educators to teach students to practice in complex work environments from the
beginning of their nursing program. This means that we need to re-think how we teach
fundamentals. Given the complexity of nursing work, just what IS fundamental to
nursing practice?
One way to think about introducing students to complex work environments and how
these environments influence patient safety and quality of care is consider alternative
clinical activities for students followed by a post-clinical debriefing session for faculty,
clinicians and students to discuss what they have learned and the implications for
practice.
Consider the following example:
A group of 8 beginning students is assigned to a long-term care or rehabilitation setting
for their initial clinical experience.
 Three students are assigned 1 patient each and, just as before, they are
expected to provide basic (personal) care to this patient
 Three students are provided with the following questions to investigate for an
assigned group of 5-7 patients on this particular unit :
o What personal care is needed by this group of patients? Do different
groups of patients have different care needs? How do you know? Steve:
make the blue text appear in a side bubble

QSEN Competencies and KSAs
 Patient-centered care:
o Assess levels of physical and emotional comfort
 Evidence-based practice:
o Describe reliable sources for locating evidence
reports and clinical practice guidelines
o Explain the role of evidence in determining best
clinical practice
o Question rationale for routine approaches to care
o Over the past week, has this care has been provided? (When and by
whom?)

QSEN Competencies and KSAs:
 Teamwork/Collaboration
o Clarify roles and accountabilities under conditions of
potential overlap in team member functioning
o Communicate with team members, adapting own
style to needs of the team and situation
o Assert own position/perspective in discussions about
patient care
o What outcomes do you observe that may have resulted from this care?
How many of these are nursing sensitive?

QSEN Competencies and KSAs
 Quality improvement
o Describe strategies for learning about the outcomes
of care in the setting in which one is engaged in
clinical practice
o Recognize that nursing and other health professions
students are parts of systems of care and care
processes that affect outcomes for patients and
families
o Use quality measures to understand performance
o Use tools that are helpful for understanding variation
o Identify gaps between local and best practice
 Informatics
o Use information management tools to monitor
outcomes of care processes
o How do you know if the care provided was adequate or appropriate to
each patient’s situation?

QSEN Competencies and KSAs:
 Quality Improvement
o Seek information about outcomes of care
o Use tools that are helpful for understanding variation
o Identify gaps between local and best practice
o Appreciate how unwanted variation affects care
o Appreciate the value of what individuals and teams
can do to improve care
o How do these patients experience receiving personal care?


QSEN Competencies and KSAs
 Patient-centered care
o Elicit patient values, preferences, and expressed
needs
o Value active partnerships with patients in planning,
implementing and evaluating care
 Evidence-based practice
o Participate effectively in appropriate data collection
and other research activities
o Value need for continuous improvement in clinical
practice based on new knowledge
Two students work with experienced staff nurses to provide care to the nurses’
assigned group of patients. By the end of the shift, the students report on the
following questions:
o What are the barriers (real or potential) to patients receiving personal care
in this unit?

QSEN Competencies and KSAs
 Safety
o Communicate observations or concerns related to
hazards and errors to patients, families and team
o Participate appropriately in analyzing errors
o Engage in root-cause analysis rather than blaming
when variation occurs

o Use national patient safety resources for own
development
Informatics
o Identify essential information that must be available in
a common database to support patient care
o Navigate the electronic health record
During post clinical the faculty member, staff nurses and students discuss their
experiences, noting the differences in perspectives based on the different assignments
above. As students identify the key elements of complex work environments, the group
can explore ways of managing this complexity, and the meaning and significance of
each proposed alternative. Similarly, if problems or deficiencies are identified faculty,
students and staff could begin a series of PDSA cycles or complete a root cause
analysis to identify possible improvement strategies. Making activities such as this a
common activity for students will allow future students to assess data over time so they
can begin to investigate the impact of the strategies previous groups have proposed or
new theories for addressing persistent problems.