N4K10
Course Manual
Professional Nursing Practice VI
Winter 2022
N4K10 Course Manual Winter 2022
Table of Contents
Nursing 4K10 Course Manual .................................................................................................... 3
Evaluation Measures ................................................................................................................. 3
Course Expectations - N4K10 .................................................................................................... 4
Reflection in Level 4…………………………………………………………………………………………………………………………..6
Learning Plan Guidelines in Level 4 ......................................................................................... 14
N4K10 Discussion Exercise……………………………………………………………………………………………………………….22
Entering a Community of Practice (COP)-Student-tutor meeting #2 ..................................... 23
N4K10: Interaction between the learning community (SON) and practice community ........ 24
Expectations of the Professional Practice Tutor and Preceptor ............................................. 28
Expectations for the Professional Practice Triad Meeting ...................................................... 31
Expectations for the Tutor and Student and expectations for the student-tutor meetings .. 32
Integration of Level 4 Professional Practice Concepts in Student-Tutor Meetings ................ 35
Clinical Reasoning (CRW) and Judgment: Level 4 (Student-tutor meeting #3)…………………....36
Clinical Reasoning Worksheet (CRW)………………………………………………………………………………….36
EIDM Worksheet: Level 4 (Student-tutor meeting #4) ........................................................... 42
Transition: Level 4 (Student-tutor meeting #5)………………………………………………………………….44
Delegation………………………………………………………………………………………………………………………….45
Reporting Medication, Treatment Errors or Near Misses....................................................... 47
Medication Administration–Safety Considerations .............................................................. 477
Figure 1: Conceptual framework for organizing competencies .............................................. 59
Glossary of Terms for Registered Nurse ’s Roles .................................................................... 59
References ............................................................................................................................... 61
Submission of Final Grades and Evaluation Forms ................................................................. 62
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Nursing 4K10 Course Manual
Evaluation Measures
Evaluation Component
Date Due
Professional Practice
(PP)
24 hours/week for six weeks, 35-36 hours per week for
six-seven weeks, Minimum of 360 hours total by end of
term April 12, 2022.
Triad Meetings
(Student- TutorPreceptor)
2 required per term (midterm and final) Triad meeting can be
held by phone or videoconferencing. Additional triad
meetings are optional.
Student-Tutor meetings
Midterm
Professional Practice
Performance
Evaluation
1. Self
2. Tutor
3. Preceptor
Learning Plan (LP)
Reflections
Biweekly meetings for 90 minutes (1.5 hrs. in length)
with tutor & groups of about 7 students scheduled in
student’s timetable. The student-tutor meetings are not
part of total PP hours. The student tutor meetings will
occur virtual synchronous. Attendance is mandatory.
Student’s performance includes preparation and
engagement in student-tutor meetings including all
agenda items. See Learning sequence for agenda items.
Progressing towards meeting learning outcomes/or
failing.
Triad meetings: Week 6 or 7 (within professional practice
time). Triad meeting can be held by phone or
videoconference. Students submit self-evaluation to drop
box in Avenue to Learn (A2L) prior to the triad meeting.
Students submit preceptor evaluation in drop box in A2L
prior to triad meeting.
Ongoing. Students submit to A2L.
Draft developed and submitted by week 4, by Friday midnight,
completed and submitted by week 11, by Friday midnight.
Total of two reflections. Critical reflection due week 3 &
Reflective Summary due week 11, by Friday midnight of those
weeks. Integration of quality literature is required. Use APA
7th edition for references and citations. Font size 12 pt., Times
New Roman, Calibri or Arial. Submit to A2L.
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Pass /Fail
Triad meeting: Week 12 or 13 (within professional
practice time). Triad meeting can be held by phone or
videoconferencing.
Students submit self-evaluation to drop box in (A2L) prior
to triad meeting. Students submit preceptor evaluation
in drop box in A2L prior to triad meeting.
Note: All evaluation measures in above table contribute to the evaluation tool.
Final Professional
Practice Performance
Evaluation
1. Self
2. Tutor
3. Preceptor
Course Expectations - N4K10
In addition to the required hands-on practice experience, students are expected to meet other
course expectations that are designed to maximize their learning toward the course learning
outcomes. Prior to attending clinical students are expected to review public health guidelines
on PPE and upload a screen shot of completion into A2L drop box. The link will be provided in
Avenue to Learn announcements for students. Students are expected to submit schedules, PP
log and all evaluative measures in the drop box on A2L. Course expectations include the
following:
1. Learning Plan – see Learning Plan Guide included.
The Professional practice Tutor and preceptor must be consulted during the development
of the plan to ensure that it meets the requirements of the course. A learning plan draft
is completed within the first four weeks of the term. See Learning Sequence. The
learning plan may be revised throughout the semester, but no revisions after week 11.
2. Reflections – two (2) reflections to be submitted on A2L (1 critical reflection & 1 reflective
summary); see Reflective Practice Guide included-provides options for reflection models
3. N4K10 Discussion Exercise (two parts): 1. Entering a Community of Practice Exercise – see
description under “Entering a Community of Practice Exercise”.
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4. Student-Tutor meetings – the tutor and students will meet biweekly for 90 minutes in
groups, as scheduled in student’s timetable. Additional individual meetings at discretion of
faculty. See expectations under “Student-Tutor Meetings”.
5. Student-Tutor-Preceptor (Triad) meetings – Triad meetings will be held at midterm, and
final evaluation, with additional meetings as needed at discretion of faculty; see
expectations under “Student-Tutor-Preceptor (Triad) meetings”
6. Portfolio of previous professional practice performance and evaluations – Students are
encouraged to maintain a portfolio which contains the following: 1) feedback and
evaluations provided by tutors in previous professional practice settings; 2) previous
reflections and learning plans (optional). This portfolio can be provided to current
professional practice tutors at their request so that student learning and tutor guidance are
optimized.
Reflective Practice Guide
N4K10 Reflection Expectations
•
•
Reflections: Students are expected to submit a total of two (2) reflections – one (1)
Critical Reflection Week 3 and a Reflective Summary on Week 11 (see learning
sequence). Students are expected to submit reflections in the drop box on A2L. The
expectation is 3-5 pages for each reflection before references. References are
required. Follow APA 7th edition format for references. Use Font 12 pt. Times New
Roman, Calibri or Arial.
Students can choose one or more of the Level 4 Reflection Models on the following
pages as a framework for the Reflections. Students do not need to use all Models
presented.
Reflective Summary
A Reflective Summary is completed and submitted Week 11. This is a reflection of your personal
and professional journey this term viewed through a critical lens. Respond to the questions
posed for each term (below). You do not need to use a reflective framework. You may find it
very valuable to review your journal entries and reflections from previous years as well as your
journey throughout the years of your BScN program! Integrate key resources. Follow APA 7th
edition for references and cite previous work. The Reflective Summary needs to be sufficiently
different from any previous submissions.
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N4K10 Your Reflective Summary should Include:
As you reflect on your educational experience in the BScN program and anticipate your
transition from student nurse to membership in the nursing profession as a Registered Nurse,
take some time to think about and describe:
•
•
•
•
•
•
How you have changed as a person throughout the BScN program [becoming a
registered nurse]?
The qualities you have to offer to the registered nursing profession from yours (internal)
and others’ (external) perspectives [being a nurse].
The qualities you still need to develop as you enter the registered nursing profession
[belonging in nursing].
The internal strategies that you feel you now possess to assist you in your journey from
BScN nursing student to professional registered nurse [transition and integration into
the profession of nursing].
Your career goals and aspirations as you anticipate your future employment as a
registered nurse.
Demonstrate depth in your thinking and writing and Integrate quality literature.
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Level IV Reflection Guide and Models
Reflection in Level 4
Overall Goal
Throughout the BScN program students learn to internalize and value reflection as a lifelong
process to grow both personally and professionally. Students graduate as beginning critically
reflective practitioners.
Level 4 Reflection Goals
1. Journaling is developed as a strategy for students to explore, understand and support
their ongoing personal and professional growth in the clinical setting.
2. Critical incident reflection through journaling is recognized and valued as a strategy to
explore, understand, learn, grow, and inform future nursing practice.
3. Written reflections (shared with the tutor) are perceived as a “safe place to wonder,
discover, probe, question, vent and grow)” to receive respect, support, encouragement,
validation, and coaching of the reflective process, critical thinking, application of new
concepts and professional growth from the tutor.
4. Broader perspectives as relevant to curriculum and clinical context/experiences are
considered in reflections such as social, political, economic and leadership
issues/influences.
5. Reflective frameworks are experimented with, modified as necessary and used to
support the development of reflective skills. These include expanded LEARN (CNO,
1996); Burrows (1995); the WHAT Model (Driscoll & Te, 2001) and Johns (1998) Model
of Structured Reflection. Students may find and use other frameworks to guide
reflections.
6. Tutor feedback and ongoing experience with reflection enables the development of
deeper levels of reflection – moving towards critical reflection.
7. Increased critical thinking is fostered and integrated into reflections.
8. Integration of literature (theory, frameworks, research, practice guidelines, concepts,
etc.) when students need to look to this information to support their analysis,
understanding and revisions as the context warrants.
N4J07/N4K10
Self & Others
Reflection is used to:
•
•
•
•
Enhance awareness of and examine feelings of Self and Others.
Recognize and examine when own knowledge base is insufficient.
Examine assumptions, values, beliefs, and behaviours (Atkins & Murphy, 1993)
Critical analysis of what, how and now beginning why.
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•
•
•
Increased critical thinking is fostered and integrated into reflections; increased critical
analysis of the what, how and now an increasing focus on the why.
Integrate relevant Level 4 issues (social, political, economic, professional and leadership
issues as well as exit to practice issues and preparation).
Increasing integration of literature (theory, frameworks, practice guidelines, concepts,
research, etc.) to support analysis, understand and revisions
Students consider others’ perspectives (i.e., client, family, nurse, peer); to question and
examine assumptions, values, beliefs, and behaviours, and to explore/integrate Level 4 issues
through dialogue and supportive, caring, reflective comments from tutor on written reflections.
Models
Model 1: LEARN (CNO, 1996)
Look back –
• Play back the personally meaningful experience in your head like a video. Play back
every detail.
Elaborate in writing/discussion –
• What happened? What did you experience, think, feel, do?
Analyze –
• What influenced this experience- what made things happen as they did?
• What made it Positive? Negative? Interesting?
• Were there any differences between what you anticipated and what you experienced?
Why do you think this happened?
• What has this reflection helped you to learn–about yourself? Anything else?
• Have you learned anything about what you value / believe?
Revise & New Trial
• Can you use this new learning in the future? Discuss this.
• Any learning issues identified (learning questions, gaps?)
• Anything you might consider doing now or revising?
Model 2: Three Stage Reflective Cycle
In STEP 1, nurses ask those questions that will support making sense of the situation on which
they want to reflect. Questions include:
• What exactly happened?
• Why did we deal with the situation in that way?
• What else could be happening?
• What was it like from the patient’s perspective?
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•
•
•
What are my feelings about the situation?
How did it affect me?
What was the impact on us as a team when that happened?
STEP 2: Looking closer. This step involves actively engaging with the questions from step 1.
Reflective practitioners do what is needed to find out more, “zoom in” on experiences and
feelings, “slow down” their own thinking and actions for further contemplation and open
themselves up to a variety of different (perhaps contradictory) perspectives. In this step,
reflective practitioners try to find ways to articulate the phenomena that were noticed in step 1
and to be aware of all the relevant underlying assumptions that are prevalent in their own
practices.
STEP 3: Transformation
This phase is all about turning sense making into action. Using observations from the first step
in conjunction with the insights gained from “looking closer”, the transformation phase is about
finding ways to articulate content and process in a format that allows positive changes to be
made. Like all useful reflective practices, the aim of this phase is to take action that leads to
better practices and, ultimately, service improvement (Oelofsen, 2012, p.23).
From Oelofsen, N. (2012). Using reflective practice in frontline nursing. Nursing Times, 108(24),
22-24.
Model 3: Lasater and Nielson (2009) reflection model
Reference Lasater, K. & Nielsen, A. (2009), Reflective journaling for clinical judgment
development and evaluation. Journal of Nursing Education, 48 (1), 40-44.
Step 1
• Students use the Guide for Reflection (Nielsen et al, 2007) as a communication tool with
faculty. The tool provides a structure for student reflections. The guide is based on
Tanner’s Clinical Judgement Model.
• Students are also required to keep a clinical log with specific detailed information about
patients, their learned skills and literature sources they have used.
Step 2
• Along with this learning activity the Lasater (2007) Clinical Judgement Rubric is used to
assess and communicate about student thinking and progress towards development of
clinical thinking.
Outcomes
This article provides outcomes from faculty and student perspectives including the following:
• Faculty’s opportunity to view their student’s thinking and clinical judgment
• Students identified positive feedback in having a framework for evaluating clinical
judgement, seeing their own progress, and developing confidence.
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Model 4: Schon (1983)
Reflection in action:
draw on tacit
knowledge to reflect
on behavior as it
happens, so as to
optimize the way you
address immediate
issues or problems
→
Reflection on action:
reflecting after the
event, to review,
analyze, and evaluate
the situation, so as to
gain insight for
improved practice in
future
→
Ladders of reflections:
action, and reflection on
action make a ladder.
Every action is followed
by reflection and every
reflection is followed by
action in a recursive
manner
Model 5: Hermeneutic Circle Chris Johns Part A and B
Part A
Hermeneutic Circle
nd
Johns, C. (2004). Becoming a reflective practitioner, 2 ed. Oxford: Blackwell Publishing.
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Part B
nd
Johns, C. (2004). Becoming a reflective practitioner, 2 ed. Oxford: Blackwell Publishing.
Model 6 What & How (Mezirow, 1990)
Content and Process Reflection – What & How (Mezirow, 1990)
Examples of Tutor Comments to Foster What and How in reflections:
What happened? How did this happen? What were you feeling? Thinking? Doing?
What was the experience for you?
How did this make you feel? Act in this situation? For what reasons?
Was the experience what you expected? If yes, in what way? If no, how was it different? For
what reasons?
How did you develop that belief about yourself? What did you learn about yourself?
How will you use this insight in the future?
What was the meaning of this for you?
How do you feel about this situation now?
What was the learning for you?
How do you plan to use this rich learning/insight in the future?
How will this influence your future nursing practice?
What did you learn about “good practice?”
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Why Premise or Critical Reflection (Mezirow, 1990)
What was the reaction of those around you? What was the client (or family or nurse…) feeling?
Thinking? Doing? For what reasons (why)?
How did your response influence the client? Family? For what reasons? How may you have
reached out to them in this situation? What prevented you from doing this at the time (why)?
How do you think your previous experience might have influenced your feelings and actions in
this situation? Why or for what reasons did it have such a profound influence on you at this
time?
How can you use your new insights/learning with future similar situations? How do you think
this might influence the outcome? For what reasons (why)?
How can you access the important information you have so clearly identified?
Have you considered exploring…?
What is it that frightens you about graduating? For what reasons?
Where does this assumption or belief stem from? I encourage you to think about this.
Suggested Reading
Bain, J., Mills, C., Ballantyne, R., Packer, J. (2002). Developing reflection on practice through
journal writing: Impacts of variations in the focus and level of feedback. Teachers and
Teaching: Theory and Practice, 8(2), 171-196.
Bilinski, H. (2002). The mentored journal. Nurse Educator, 27(1), 37-41.
Brookfeild, S. (1995). Becoming a critically reflective teacher. Jossey – Bass.
Brown, B. Matthew-Maich, N., Royle, J., (2001). Fostering reflection and reflective practice. In E.
Rideout (Ed), Transforming nursing education through problem-based learning. Jones
and Bartlett.
Freshwater, D. (2002). Therapeutic nursing: Improving patient care through self-awareness and
reflection. Sage Publications.
Heinrich, K.T. (1992). The intimate dialogue: Journal writing by students. Nurse Educator, 17, 17-21.
Matthew-Maich, N. Brown, B., Royle, J. (2000). ‘Becoming’ through reflection and professional
portfolios: the voice of growth in nurses. Reflective Practice, 1(3), 309-324.
Paterson, B.L. (1995). Developing and maintain reflection in clinical journals. Nurse Education
Today, 15, 211-220.
Westberg, J. & Jason, H. (2001). Fostering reflection and giving feedback: Helping others learn
from experience. Springer Publishing Co.
Williams, B. (2001). Developing critical reflection for professional practice through problembased learning. Journal of Advanced Nursing, 34(1), 27-34.
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References
Brookfield, S. (1995). Becoming a critically reflective teacher. Jossey Bass.
College of Nurses of Ontario (1996). Professional profile: A reflective portfolio for continuous
learning. CNO.
Driscoll, J. & Te, B. (2001). The potential of reflective practice to develop individual orthopaedic
nurse practitioners and their practice. Sage Publications.
Freshwater, D. (2002). Therapeutic nursing: Improving patient care through self-awareness and
reflection.: Sage Publications.
Johns, C. (1998). Opening the doors of perception. In C. Johns and D. Freshwater (Eds.),
Transforming nursing through reflective practice. Blackwell Scientific Publications.
Mezirow, J. (1990). Fostering critical reflection in adulthood. Jossey-Bass.
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Learning Plan Guidelines in Level 4
We believe that developing and completing a comprehensive Learning Plan in Level 4 is a
dynamic process that will evolve over the course of the academic term as the students’ learning
needs unfold. Depending on the student, the professional practice context, and the student’s
personal Knowing in this practice context, learning aims may be adjusted as the term
progresses.
We believe learning plans are not static documents: the development of the Learning Plan
begins with reflection on the student’s authentic Being and Becoming a professional nurse
transitioning to professional practice. As students’ learning incorporates not only what they
know and can do, but also who they are as persons, learning can transform them over time.
This process of becoming is always open and incomplete, as well as constrained by current
understanding, and relations with others. Therefore, Learning Plans are re-visited and refined
through on-going dialogue with the Tutor and Preceptor.
The Learning Plan reflects a solid understanding of the principles of self-directed learning,
framed by the learning outcomes, and ultimately evidenced in the Professional Practice
Evaluation Form. We believe Learning Plans are well suited for use in all professional practice
contexts and promote a student’s Acting as a nurse. Learning plans enable students to engage
in continuous dialogue and to receive feedback from multiple individuals, particularly from the
Professional Practice Tutor and Preceptor. Through this, the Learning Plan facilitates and
supports a student’s Belonging within the nursing profession.
Learning Plans facilitate self-directed learning by allowing students to blend learning outcomes
with their own learning questions based on reflection of personal learning needs and of the
community of practice into which they are entering. A Learning Plan represents an on-going
dialogue between student and tutor: clarifying what the student intends to learn (learning
questions); identifying how this will be accomplished (resources and activities); specifying the
time period for demonstrating evidence of accomplishing the learning goal/question; and
determining how this evidence will be evaluated (evaluation criteria). It is a working document
to be used by the student, preceptor, and tutor in developing learning questions and selecting
learning opportunities. It requires sharing of expectations and goals by all involved in the
student’s learning: the learner, preceptor, tutor, and other individual resources.
The learning plan is intended to:
1. Incorporate related learning outcomes and provide direction for the learning activities
outlined in the plan. The learning plan should outline how the specific learning activity
relates to meeting the learning outcomes for that course and specific to the placement.
2. Allow students to base learning questions after reflecting on personal strengths and
limitations in professional practice.
3. Identify resources and activities to meet these learning questions.
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4. Identify measurable success indicators (evidence) that demonstrate achievement of the
learning questions. Criteria for assessing the evidence are sourced through the
literature.
5. Provide a timeline for students to achieve personal learning questions.
The student will:
1. Prepare a draft of the learning plan to discuss with the tutor within the first several
weeks of the course (see Learning Sequence for due dates). The discussion will focus on
the student’s reflection on his/her own personal Knowing, Acting, and self-efficacy, and
whether learning questions are realistic within the context of the practice environment,
and the learning outcomes.
2. Negotiate and revise the learning plan with the tutor, with input from preceptor. The
tutor may need to assist the student in interpreting the learning outcomes.
3. Implement the learning plan and demonstrate a variety of evidence that support
achievement of learning questions according to target dates specified in the learning
plan.
4. Review target dates on the plan and collaborate with tutor on changes in the plan.
The tutor will:
1. Facilitate students’ Becoming a professional nurse by engaging in on-going dialogue
around learning goals, resources and activities that support Knowing, and Acting, and
proposed evidence, and criteria for evaluation sourced through the literature.
2. Recommend changes that will strengthen the plan, increase congruence with the
professional practice setting and learning outcomes, enhance learning opportunities,
and/or facilitate timely completion of the learning plan.
3. Provide ongoing feedback, guidance, and support, encouraging multiple ways-ofknowing, Evidence-informed Decision Making (EIDM), and development of clinical
reasoning and clinical judgment. The learning plan provides valuable evidence of
student learning which can then be documented on the Professional Practice Evaluation
Form.
4. Be responsible for evaluating the learning plan and negotiated evidence.
5. Provide encouragement, support, and coaching – using prompts, probes, and
questions – to help develop a student-focused, student-centered Learning Plan.
The preceptor will:
1. Promote students’ Being and Acting as a professional nurse by supporting the student
to meet learning plan goals, helping to identify what is realistic within the professional
practice setting and the course timeline, and acting as an assessor of evidence where
appropriate.
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Developing Your Learning Plan
To develop your own blueprint for learning in your professional practice courses, review the
following steps and answer the questions at the end of the sections.
Reflect on your learning needs and your learning goal or focus.
Consider the learning outcomes outlined in the course manual. Then reflect on your
experience, personal Knowing, and past feedback, and evaluations. Review the final page of
your professional practice evaluation form completed at the end of your previous
professional practice course. The section that outlines your strengths and areas for
improvement contributes significantly to identifying your major learning gaps/issues.
Consider the community of practice you are entering and identify the knowledge you will
need to function effectively in this setting– this will be the focus of your learning. Move
beyond simply focusing on the knowledge that all students in that area must know to
provide safe patient care (e.g., specific assessments, basic skills required).
For example, if you are going to a paediatric unit, all students must have knowledge related
to growth and development, family-centered care, administration of pediatric medications.
Identify your gaps in knowledge when dealing with paediatric patients and their families
(e.g., parental response to chronic illness in childhood). Upon further reflection you may
identify that you lack knowledge in carrying out procedures with paediatric patients and you
also have some ethical concerns surrounding your client’s care giving.
Both your tutor and/or preceptor may assist you in recognizing your learning needs and
identifying where your focus should be for your learning plan.
When identifying your learning needs, you will want to consider:
➢ Your own inner resources and strengths. Identify current values and beliefs that may
influence your practice in this new clinical setting.
➢ What specific learning gaps you have in this clinical setting?
➢ What resources are available in the clinical setting to help you meet your learning
needs?
➢ What evidence-based resources you will utilize?
Specify your learning questions
Match your own personal knowing and acting as a professional nurse with the learning
outcomes to design learning questions. In writing your learning questions consider the
community of practice you are entering.
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Questions to consider when developing personal learning questions:
➢ What facets of clinical reasoning and clinical judgment would you like to develop
further?
➢ Have you considered the specific attributes (e.g., resources, constraints, and
expectations) of your community of practice?
➢ What is your current professional identity as a ‘nurse’?
➢ Are the learning questions realistic and can they be accomplished in the setting within
the given time frame?
➢ Will it be possible to evaluate whether you have met your learning questions?
Reassess learning needs after entering the community of practice
After you have spent several days orienting to your professional practice setting, you may find
that you have reaffirmed or reassessed your learning needs/focus. If you have reaffirmed them
and, in dialogue with your tutor/preceptor, feel that you can meet all your learning objectives,
you may implement your plan. However, if you have identified other learning needs or new,
exciting learning opportunities, now is the time to build them into your learning plan. You are
encouraged to continue to identify learning questions throughout the term, completing a
learning plan for each.
Specify learning resources and activities
Identify and describe the different resources and activities you will use to accomplish each
learning question. Be creative in choosing resources and activities, try something new and
assess the effectiveness of a different strategy. Remember, you are a student and have license
to explore the possibilities. Include a list of resources, both material (e.g., journal articles, texts,
pamphlets etc.) and human (e.g., tutor, leader of a workshop/seminar, clients). The more
specific your list of resources and activities, the more helpful your peers, tutor and preceptor
can be in offering suggestions.
Questions to consider when identifying learning resources and activities:
➢ What resources will you use to answer your learning questions?
➢ Why did you select a particular resource?
➢ What other resources have you considered?
➢ What activities would you consider doing to assist you with your learning?
➢ Is the activity feasible within the learning situation and the available timeframe?
➢ Are there other resources, especially human, that should be considered?
Specify Evidence and Evaluation Criteria that demonstrate accomplishment of your learning
questions
Now, specify the evidence you plan to submit to demonstrate you have answered your learning
questions. It is important to include the due dates for completion of each evidence/activity. A
column has been designated on the Learning Plan Form for completion dates. Dates for
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achievement of learning questions and submission of evidence should be interspersed
throughout the term to maximize learning and assist with time management.
Questions to consider when specifying evidence of accomplishment of learning questions:
➢ Why select this particular evidence?
➢ What other evidence have you considered?
➢ Are there other ways of knowing you can incorporate?
➢ How and when will you provide this evidence, and to whom? Specify target dates for
completing each of your learning activities.
Specify how the evidence will be evaluated
Specify the criteria by which the evidence will be evaluated. The criteria should vary according
to the type of learning question and evidence. Criteria usually come from the literature that
speaks to effective nursing practice, e.g. What is caring communication? What is effective
interprofessional communications? What is effective decision making in an emergency setting?
What are guidelines for ethical practice in nursing? Forming criteria from the literature to
evaluate or ask questions of the evidence ensures that your practice is based on sound practice
knowledge that has been judged worthy by the profession.
Determine who will be the evaluator and why they are qualified to evaluate the evidence. How
will they provide their evaluation, based on the evaluation criteria you provide? Consider
whether the feedback will be judgments from rating scales, descriptive reports and/or
evaluative reports, or whether it will be from analysis of a discussion you had with your
tutor/preceptor. Again, be selective and creative in seeking validation of success. You may use
a wide variety of resources including peers, preceptor, clinical staff, patients, tutor, self, etc., as
well as multiple ways of knowing.
Example:
Learning Goal: To provide effective health teaching to elderly patients and families about skin
care including the prevention, management, and treatment of pressure ulcers.
Evaluation Criteria: The preceptor will evaluate the teaching based on: whether the
patient/family’s learning needs were assessed and addressed; whether the content was
evidence based; whether the information was provided in a clear, easy to understand manner;
whether they had the opportunity to ask questions and receive adequate answers. The tutor will
evaluate the evidence and ways of knowing used to develop the teaching plan and student
reflection on effectiveness of teaching strategies.
Questions to consider when designing criteria for evaluation of evidence
Are the criteria clear, relevant, and applicable?
Are the sources for the criteria used valid and reliable and judged worthy by the profession?
How do the criteria relate to your learning questions?
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➢ Should other criteria be considered?
➢ Will the feedback gained from this evaluation be applicable to further learning?
HOW?
Review/negotiate learning plan with preceptor and tutor
Your initial learning plan is now complete. Show your learning plan to your peers who can act as
your consultants to give you responses and suggestions. Feel free to use the following
questions as a guide for soliciting feedback in the review process (Knowles, 1975, p.134). They
should be used as an ongoing evaluative tool to improve your learning plan and to make it
realistic and useful. You may choose to make some revisions and then show the draft and
finished product to your tutor and preceptor. If you are having difficulties with the first draft of
your learning plan, consult with your tutor at any time during the development process. You
should be prepared to discuss a first draft of the learning plan to your tutor and preceptor
during the first few weeks of your new professional practice placement. See Learning Sequence.
Learning Questions
➢
➢
➢
➢
➢
Are the learning questions clear, understandable, and realistic?
Do the learning questions describe what you propose to learn?
Are there other learning questions you might consider?
Do they reflect personal goals and learning outcomes?
Do the learning questions include both foreground and minimal background
questions?
Learning Resources and Activities
➢ Do the learning resources and strategies reflect EIDM and multiple ways of
knowing?
➢ Are there other activities you might consider?
Evidence
➢ Does the evidence seem relevant to the various learning questions?
➢ Is it a valid way to provide evidence of learning? (Evidence should match the type
of learning)
➢ Does the evidence demonstrate quality, variety, and creativity?
➢ Did you utilize the EIDM Level 4 worksheet or the Clinical Reasoning work sheet?
➢ Is your timeline realistic? Are the target dates specified?
➢ What other evidence might you consider?
Criteria for Evaluation of Evidence
➢ Are the criteria clear, relevant, understandable, and convincing? Based on
principles of teaching and learning? Are they sourced using valid professional
literature?
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N4K10 Course Manual Winter 2022
➢ Are the criteria congruent with the learning question(s) and activities?
➢ Are there other ways that you might consider validating the evidence?
➢ Did you include references in APA 7th edition format?
Learning Activities
1. The focus is on the student developing an individualized learning plan, in preparation for
their transition and integration into professional practice.
2. The learning plan template is the same as level 3, but it is expected that students will be
more independent in developing their learning plan at this stage. Students should be
able to identify appropriate learning questions and demonstrate reflection on personal
knowing, being, and acting as a nurse.
3. Students should include feedback from previous professional practice experiences into
their learning plan.
4. Students should continue to develop and include specific evaluation criteria (i.e., Who
will evaluate? What will be evaluated? Against what criteria?).
The development of individualized learning plans and lifelong learning skills relies on the
relationship between student and tutor as well as the triad of tutor-student-preceptor where
the student is in the center. The tutor and preceptor coach the student in developing a realistic,
relevant learning plan. In addition to addressing feedback received from previous professional
practice contexts, students will also complete a learning needs assessment based on:
✓ Reflection of the community of practice environment to identify relevant
professional practice issues.
✓ The scope of student role in this setting
✓ The current evolution of the student’s professional identity
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Template for Level 4 Learning Plan
Learning Goal
On what do I
want to focus
my learning?
Learning Questions
What specific
questions do I have
related to my goal?
Resources
What resources
can I use to help
me learn?
Activities
What activities
will I complete
to help me
learn?
Evidence
How will I
demonstrate
what I have
learned?
Due Dates
Evaluation
Criteria
How will my
learning be
evaluated?
By whom?
Against
what
criteria or
standard?
Learning Summary: Comment on the process of completing the learning plan. What other nursing roles would you
envision in this setting (e.g., political action, social advocacy, etc.)? How has this learning plan contributed to your
becoming and acting as a nurse? What went well? What would you do differently in the future?
References and Resources
Anderson, G., Boud, D., & Sampson, J. (2004). Learning contracts: A practical guide. Routledge Falmer.
Bailey, M.E. & Tuohy, D. (2009). Student nurses’ experiences of using a learning contract as a method of
assessment. Nurse Education Today, 29, 758-762.
Bloom, B. S., Krathwohl, D. R. (1968). Taxonomy of educational objectives – The classification of
educational goals, Handbook I: Cognitive domain. Longmans, Green. Assist with indicating a
focus for learning questions addressing the cognitive domain.
Challis, M. (2000). AMEE Medical Education Guide No. 19: Personal learning plans. Medical Teacher,
22,3, 225-236.
College of Nurses of Ontario. (2019). Developing SMART Goals Pub. No. 44047.htpp://www.cno.org/qa.
College of Nurses of Ontario (2019). Entry- to- Practice competencies for Ontario Registered Nurses.
www.cno.org.
Crisp, G. T. (2010). Integrative assessment: reframing assessment practice for current and future leaning.
Assessment & Evaluation in Higher Education. 1-11, July 26.
Donaldson, I. (1992). The use of learning contracts in the clinical area. Nurse Educator, 12, 431-36.
Page 21 of 62
N4K10 Course Manual Winter 2022
Knowles, M. S. (1970). The modern practice of adult education: Andragogy versus pedagogy.
Association Press.
Knowles, M. S. (1975). Self-directed learning: A guide for learners and teachers. Follett Publishing
Company.
Knowles, M. S. (1986). Using learning contracts: Practical approaches to individualizing and structuring
learning. Jossey-Bass Publishers.
Krathwohl, D. R., Bloom, S., & Masia, B. B. (1964). Taxonomy of educational objectives – The
classification of educational goals, Handbook II: Affective domain. David McKay. Assist with
learning questions in the affective and cognitive domain.
Schon, D. A. (1987) Educating the reflective practitioner. Jossey-Bass.
Smedley, A. (2007). The self-directed learning readiness of first year Bachelor of Nursing Students.
Journal of Research in Nursing, 12(4), 373-385.
Su-Ting, T.L. & Burke, A. (2010). Individualized learning plans: Basics and beyond. Academic
Pediatrics,10(5), 289-291.
Su-Ting, T, L. , Tancredi, D., Patrick, J. & West, D. (2010). Factors associated with successful selfdirected learning using individualized learning plans during pediatric residency. Academic
Pediatrics, 10 (2), 124-130.
Tompkins, C., & McGraw, M. J. (1988). The negotiated learning contract. In D. Boud (Ed.). Developing
student autonomy in learning (2nded.). Kogan Page.
Tompkins, M. & Paquette-Frenette, D. (2010). Learning portfolio models in health regulatory colleges
of Ontario, Canada. Journal of Continuing Education in the Health Professions 30(1), 57-64.
VanDeventer, C., Conradie, H., Moosa, S., Morris, G., Smith, S., Van Rooyer, M., Derese, A., & De
Maeseneer, J. (2005). The learning plan as a reflective tool for trainers of family medicine
registrars. South African Family Practice, 47(10), 17-21.
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Entering a Community of Practice (COP)-Student-tutor meeting #2
N4K10 Discussion Exercise
Becoming a nurse is about joining the community of practice (COP) represented by qualified
nurses as much as it is about learning the technicalities of nursing. (Cope, Cuthbertson &
Stoddart, 2000)
Underlying assumptions:
• We belong to multiple communities of practices in our personal, professional, and
community lives. Learning occurs as we engage with, and contribute to, these
communities. Practice communities possess explicit and tacit social practices.
•
Lave and Wenger (1991) identify 3 components of situated learning within a
Community of Practice (COP)
1. The Domain (“Competencies”): identity defined by a shared practice domain,
assuming shared competence of community members
➢ Students must understand the professional practice setting
expectations, knowledge base, and competencies required to
practice in the setting.
2. The Community (“Culture”): interaction between members around shared
activities, relationships built around learning from and sharing information
with each other
➢ Students must understand the work environment, including
relevant organizational policies defining nursing practice, social
practices, and interpersonal dynamics of the setting.
3. The Practice (“Collaborations”): members are practitioners who have
developed a shared repertoire of resources which can include
stories/histories, helpful tools/strategies, experiences, ways of addressing
problems, etc., which develop over time.
➢ Students engage with the practice setting by understanding and
integrating into the practice culture.
➢ This integration begins slowly, with the student contributing in
increasingly important ways to the community over time.
•
Learning within the COP is facilitated by the preceptor(s) and other members
(e.g., staff, educator, manager, interprofessional team) as well as through faculty
tutor supervision.
Discuss the Nurses’ Association of Ontario (2008) Workplace Health, Safety and
Well-being of the Nurse
•
•
Some examples which indicate that a community of practice has formed (Wenger,
1998, p.125):
➢ Sustained mutual relationships and shared social norms
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➢ Ease of communication because of shared experiences, stories, common language
➢ “knowing what others know, what they can do, and how they can contribute
to an enterprise”
N4K10: Interaction between the learning community (SON) and practice community
As students enter Level 4 and engage with the professional practice setting, it is important to
understand the Communities of Practice (COP) into which students enter. This involves
exploration, reflection, and discussion of the 3 components that comprise a COP: The
Domain, the Community, and the Practice. Begin by reading about what a community of
practice is, and then move to a more active form of inquiry. If at any time in the process you
encounter aspects that require further explanation, then return to some form of empiric
knowing to achieve greater depth of understanding. Steps of active inquiry include:
1) Conduct an initial scan of the new practice community, appraising the setting using the
3 components of situated learning described above. Students are encouraged to speak
to preceptor(s), staff, managers, educators, and other members of the
interprofessional/intraprofessional team and unregulated workers to supplement
personal observations.
2) Share observations, insights, and questions with the professional practice tutor at a
student-tutor meeting early in the semester (see learning sequence for due date).
3) Focus on transition and integration into the professional practice community by
“Looking up and out”. “Looking up” involves an understanding of the Macro, or
systems, level of professional practice. Examine internal organizational policies and
relevant external policy in the health care system, professional/organizational, and
socio-cultural components impacting on client populations and care delivery. “Looking
out” involves developing a personal, authentic professional identity and vision. Reflect
on the 3 components of situated learning one’s role is shaped within the practice
community.
4) Students are encouraged to add any new learning questions and learning goals into
their Learning Plan as they move through their inquiry.
5) Students are also encouraged to explore issues in greater depth through a critical
reflection.
6) Follow up and re-scan the COP environment periodically throughout the term to see
how perspectives have changed, to assess how/if/in what capacity the student has
made contributions to the practice setting and how an understanding of the COP culture
has enhanced professional practice with clients and patients. These perspectives could
also be explored further in the summative reflection.
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N4K10 Course Manual Winter 2022
Focus on transition and integration into the professional practice community by “Looking
up and out”. “Looking up” involves an understanding of the Macro, or systems, level of
professional practice. Examine internal organizational policies and relevant external policy
in the health care system, professional/organizational, and socio-cultural components
impacting on client populations and care delivery. “Looking out” involves developing a
personal, authentic professional identity and vision. Reflect on the 3 components of
situated learning one’s role is shaped within the practice community.
Examples of questions to ask from the Community of Practice components
The Domain:
“Looking up”: What competencies do I need to be an active and effective member
within my practice organization? (E.g., understanding how patient and
policies/procedures are developed)
“Looking out”: What continuing education is required on a regular basis by the
organization and CNO to ensure that I am competent and current in my practice? (E.g.,
maintaining current resume, understanding annual CNO learning plan and reflective
practice requirements)
The Community:
“Looking up”: what relevant policies in the organization for nursing practice do I need to
know? What professional nursing organizations exist in my area and how do I get involved?
(E.g., RNAO, shared interest groups, practice-specific groups/organizations)
“Looking out”: How do I represent the nursing profession to the public and in my
community? How well to I comply with the organizational policies for expected practice?
How does my being a Registered Nurse and belonging in the nursing profession impact on
the personal and civic domains of my life?
The Practice:
“Looking up”: What are the roles and responsibilities of others in the interprofessional/intra
professional team (including unregulated workers) and how do we work together in our
practice setting? (E.g., understanding communication structures and domains of
responsibility)
“Looking out”: What kind of Registered Nurse do I want to be, given my personal experiences
and my unique strengths and resources? What type of mentor do I want to be to other
Registered Nurse s in the future?
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N4K10 Course Manual Winter 2022
BScN Preceptorship Program Framework
•
•
•
Preceptorship in nursing is an approach to teaching-learning frequently utilized in
professional practice courses at the senior level when learners are making the transition
from the senior student role to that of a professional nurse.
Preceptorship is facilitated by the teaching-learning triad (student, preceptor & faculty
tutor) & experiential learning is central to this collaboration (Tran, 2008); see the figure
below.
Preceptorship is viewed within the context of professional nursing & its major domains:
practice, education, research, administration & policy.
A number of concepts contribute to successful completion of a preceptored course:
• Effective communication on is foundational to the development & maintenance of the
preceptorship triad, & it also is vital to the delivery of safe nursing care & satisfaction
with teamwork.
• Competence & caring are fundamental expectations of professional practice
experiences; students learn to perform the complex professional nursing role in ways
that exemplify both competence & caring; caring without competence would be
expected from an empathetic lay person & competence without caring would be
anticipated from a person performing a highly technical role.
• Conscience or ethical practice is critical to practice by all health professionals.
• Comportment refers to professional behaviours to which students are socialized (e.g.,
appropriate workplace grooming and attire, interaction with patients, families, & interprofessional team members), code of conduct.
• Commitment to the experience is made by all triad members; students commit to their
educational development, striving to achieve entry-to-practice competencies;
preceptors commit to acting as role models & clinical teachers & faculty tutors commit
to providing educational support & guidance to the preceptors & students during the
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N4K10 Course Manual Winter 2022
•
•
•
preceptorship experience. For more information on the preceptor role or framework
please see the Preceptorship Handbook located in Avenue to Learn Course Shell.
Collaboration occurs both formally & informally. Clinical agencies formally agree to
collaborate in students’ professional practice learning & each triad informally agrees to
form a partnership that meets the goals of the professional practice courses.
As learners, each member of the triad assists one another in developing confidence in
their respective educational roles.
Preceptors make a critical educational contribution to the future health & health care of
our citizens by shaping the profession, one nurse at a time.
References:
College of Nurses of Ontario (2019). Code of Conduct Standard. www.cno.org.
College of Nurses of Ontario (2019) Entry to Practice competencies for Ontario Registered
Nurses will take effect September 2020.www.cno.org.
College of Nurses of Ontario. (2018). Practice Standard: Decisions about Procedures and
Authority, http://cno.org.
College of Nurses of Ontario. (2017). Practice Guidelines: Supporting Learners, http://cno.org.
LeGris, J., & Cote, F.H. (1997). Collaborative partners in nursing education: a preceptorship
model for BScN students. Nursing Connections, 10, 55-70.
Molzann, A. & Shields, L. (2008). Why is it so hard to talk about Spirituality? Canadian Nurse,
25-29.
Roach, S. (1997). Caring from the heart: The convergence of caring and spirituality. Paulist
Press.
Tran, A.H. (2008). Promoting preceptors’ use of reflection with senior undergraduate nursing
students. Project completed to partially fulfill the requirements for an MSc, McMaster
University.
Please Note: This framework description is taken from the Preceptorship Handbook –
McMaster Mohawk Conestoga BScN Program 2021-2022. Students are provided with the
online handbook through Avenue to Learn. Students are expected to send the Preceptor
Handbook to their preceptor during orientation. This can be done by sending the
Preceptorship Handbook by email. All students are expected to familiarize themselves with
preceptorship as a teaching-learning modality. Reading the Preceptorship Handbook is part
of the students’ preparation for Level IV professional practice courses. The Preceptorship
Handbook and program material will be housed electronically in the Level 4 AVENUE Folder.
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N4K10 Course Manual Winter 2022
The preceptor website link is as follows: https://nursing.mcmaster.ca/current/clinicalcommunity-placements/preceptorship-program
Expectations of the Professional Practice Tutor and Preceptor
Professional Practice Tutor/Faculty
Role in the Learning:
Preceptor
Role in the Learning:
•
•
•
•
•
•
•
Facilitate student’s Being and
Becoming as a professional RN
through dialogue regarding their
development of a professional RN,
and the testing of ‘provisional selves’
by refining ways of acting and
coming to know.
Facilitate student-tutor meetings
held in person face-to-face in
classroom with planned agenda
items and learning aims. These biweekly meetings are 90 minutes and
scheduled in the student timetable
with groups of about 7 students per
meeting.
Provide coaching, mentoring, and
celebrating student’s Knowing and
their growing sense of self- efficacy
in Acting within the professional
practice context.
Promote student’s Belonging in the
nursing profession and within the
community of practice that is their
placement.
Assist students to reflect on and to
integrate previous experiences
(through courses – e.g.,
pathophysiology; personal and
professional practice situations),
EIDM, CRW and ways of knowing
into their current professional
practice
Participate in consistent dialogue
and provide formative and
summative feedback regarding
student’s professional development
over the term.
Enable and support student’s entry into
and sense of belonging within the
practice community and nursing
profession.
• Advocate on behalf of the student and
promote student’s Becoming a nursing
professional and student’s Acting
effectively in the practice context
• Exemplify understanding of
professional nursing identity through
role-modeling professional
comportment, and sharing clinical
reasoning processes and experiential
knowledge as an expert nursing
professional
• Assist the student to clarify learning
needs in relation to the specific
learning opportunities available in the
practice setting. Encourage and
facilitate the student’s use of other
professional practice resources for
learning.
• Identify alternative and additional
valuable learning opportunities for
student
How this role is actualized:
• Respond to the tutor’s email,
particularly if a triad meeting is
requested before midterm.
• Meet with the student and Professional
practice Tutor at mid-term and the end
of term to evaluate student progress.
These triad meeting can take place by
phone or videoconference.
• Conduct unit-specific orientation
sessions for students and be available
to dialogue with the student
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N4K10 Course Manual Winter 2022
Professional Practice Tutor/Faculty
Role in the Learning:
•
Help students to identify personal
and professional development and to
“look forward and outward” towards
future professional practice upon
graduation and novice registered
nurse.
How this role is actualized:
• Email the preceptor with welcome,
contact information and expectation.
• Meet with the student and preceptor
at mid-term and the end of term to
review and clarify course learning
outcomes. These are triad meetings(see further details below). The triad
meeting can take place by phone or
video conferencing.
• Meet with each of the groups of
about 7 students biweekly to
facilitate planned agenda items,
learning aims, updates, dialogue
regarding progression, and coaching
regarding next steps. The tutor has a
weekly meeting with alternating
groups of students. See learning
sequence.
• Maintain communication via
McMaster email, and student-tutor
meetings on an on-going basis as
required.
• Determine Pass or Fail status for
student and communicate with the
student directly. The tutor determines
the final pass for this course.
•
• Maintain and facilitate, as informal
liaison, on- going collaboration
between student, preceptor,
learning community (SON), and
practice community.
• Acknowledge the professional
contributions of preceptors formally
Preceptor
Role in the Learning:
•
•
•
•
•
•
•
throughout the term
Provide informal and formal ongoing
feedback to the student about his/her
performance throughout the term
Inform Professional Practice Tutor of
student progress.
Inform tutor if the student is having any
difficulties and or attendance issues.
Provide formal feedback by completing
the midterm and final evaluation forms
with comments and examples to
promote the learning process.
Consider participating in Preceptor
Education offered through the
Preceptorship Program. For further
information, contact Alida Bowman at
bowmanam@mcmaster.ca
The student should be providing the BScN
Preceptorship Handbook as a reference to
their preceptor. This can be found on A2L
or the website
https://nursing.mcmaster.ca/current/clini
cal-communityplacements/preceptorship-program
Receive feedback on own
performance through the Preceptor
Performance Form completed by the
student. If you have a Clinical Faculty
appointment, these forms may be
forwarded to the Associate Dean
(Nursing); otherwise, you may use
them as performance appraisals.
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N4K10 Course Manual Winter 2022
Professional Practice Tutor/Faculty
Role in the Learning:
•
•
•
Preceptor
Role in the Learning:
and informally. Tutors are
encouraged to forward letters for the
preceptor to use in their professional
development portfolio.
McMaster: Submit Preceptor’s
name and contact information by
email to Mediha Kadic at
kadic@mcmaster.ca by Week 4 of
the term.
Mohawk and Conestoga: Submit
Preceptor’s name and contact
information to Priscilla Patterson
priscilla.patterson@mohawkcollege
.ca
Or Susanne Bush at
sbush@conestogac.on.ca
Receive feedback on own tutoring
role through Mosaic. Evaluation of
the Professional Practice Tutor
Performance is completed by the
student online.
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N4K10 Course Manual Winter 2022
Expectations for the Professional Practice Triad Meeting1
•
•
•
•
•
•
•
•
•
•
•
•
Professional Practice Tutor/Faculty
Preceptor
Email the preceptor with welcome, contact
• Respond to the tutor’s email, particularly if a
information and course expectations. Establish
triad meeting is requested before midterm.
communication plan by email.
• Meet with the student and Professional Practice
Meet with the student and preceptor at midTutor at midterm and at the end of term to
term and the end of term to review and clarify
review and clarify course learning outcomes as a
course learning outcomes as a minimum.
minimum. Note: the preceptor will be notified
Tutors may have triad meetings by phone or
by the student if the triad meeting will take
video conferencing. The triad meeting may
place by phone or video conferencing
need to occur more often in order to support
the student’s success at the discretion of
faculty.
At the Midterm Evaluation (by week 7 of the term)
Complete Professional Practice Evaluation
• Signs PP log after each shift.
Form designated for tutors and assign
• Recommend satisfactory/unsatisfactory
progressing to Pass or Fail status. The
professional practice performance rating to
preceptor provides feedback, progress to date
professional practice Tutor for the student.
and recommendations of Pass/Fail grade to
• Provides written and verbal formative Midterm
tutor.
evaluation through the Professional Practice
Provide written and verbal formative Midterm
Evaluation Tool designated for preceptors.
evaluation
Ensure student submits PP log signed by
preceptor with completed hours at midterm.
Contact course lead/coordinator if student is
not progressing or FAILING at midterm.
At the Final Evaluation (by the end of week 12 of the term)
Complete Professional Practice Evaluation
• Signs PP log following each shift
Form.
• Recommend satisfactory/unsatisfactory
Assigns Pass or Fail grade.
professional practice performance rating to
Professional Practice Tutor for the student’s
Provide written and verbal summative
being and acting in the nursing role
evaluation
• Provide written and verbal summative Final
Ensure student submits self-evaluation and all
evaluation through the Professional Practice
evaluative measures to A2L drop boxes.
Evaluation Tool designated for preceptors.
Ensures the student submits completed PP log
Options available Evaluation Form:
signed by preceptor with total hours to A2L.
o Hard copy (then scanned)
After the student submits their final selfo Electronic version (available on AVENUE
evaluation to the drop box on A2L and the
and can be provided by student)
preceptor evaluation prior to the triad
meeting, the tutor uploads the final Tutor
1
The Professional practice Triad involves the Student, the Professional practice Tutor and the Preceptor
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N4K10 Course Manual Winter 2022
•
•
Evaluation and publishes the final tutor
evaluations on A2L in the student drop box.
Notifies Course lead/coordinator if student has
not passed.
Note: The evaluation form does not require a
signature as it is submitted to A2L by student
with ID.
Expectations for the Tutor and Student and expectations for the student-tutor meetings
Professional Practice Tutor/Faculty
Student
Student-tutor meetings are in groups, and scheduled bi-weekly in student timetable
Student-tutor meetings are held virtually in ZOOM.
•
•
•
•
•
•
•
•
•
•
IMPORTANT:
Attendance is mandatory for student-tutor meetings held virtual synchronous. These tutorials are
facilitated by the tutor and assessments will be noted on mid- and final-evaluation tools
Students must keep professional practice tutor and preceptor updated with a current shift schedule
and submit schedule planner to A2L.
Changes to the schedule can only be made after consultation with the tutor and preceptor
Students must follow the preceptor’s schedule as much as possible AND must schedule contiguous
professional practice shifts as much as possible.
Professional practice time cannot be missed because of other course work, outside employment or
extra-curricular activities
Students submit the Professional Practice Log (PP log) signed by preceptor at midterm and final into
the drop box on A2L.
Facilitate student’s Being and Becoming as a
professional Registered Nurse
Facilitate student-tutor meetings held virtual
synchronous with planned agenda items and
learning aims. Bi-weekly meetings are 90
minutes and scheduled in student timetable
with groups of about 7 students per meeting.
Provide coaching, mentoring, and celebrating
student’s Knowing and their growing sense of
self-efficacy in Acting within the professional
practice context.
Promote student’s Belonging in the nursing
profession and within the community of
practice that is their placement.
•
•
•
•
Attend all student-tutor meetings as scheduled
in timetable, prepare for learning in group
meetings and engage in the teaching and
learning process.
Personally, develop and maintain the courage
and will to learn in a more independent learning
situation; be prepared to reflect on and
articulate personal growth in Being and
Becoming a professional Registered Nurse with
an authentic voice. This will signal a transition to
ownership of your own professional voice.
Review learning outcomes and expectations on
an ongoing basis.
Contact professional practice tutor by email
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N4K10 Course Manual Winter 2022
Professional Practice Tutor/Faculty
•
•
•
•
•
•
•
•
Assist students to reflect on and to integrate
previous experiences (through courses – e.g.,
pathophysiology; personal and professional
practice situations), EIDM, and ways of
knowing into their current professional
practice
Participate in consistent dialogue and provide
formative and summative feedback regarding
student’s professional development over the
term.
Collaborate with students regarding process
for managing medication and/or treatment
errors. Notify the level 4 lead/coordinator if an
incident or near miss has occurred and debrief.
Complete a progress note for student
debriefing and send to lead/coordinator.
Upload all progress notes to A2L under student
name under final evaluation.
Collaborate with students regarding process
for managing occupational health and safety
injuries or incidents including student seeking
first- aid if needed and following agency
procedure and notify the site-specific
lead/coordinator.
Help student to identify personal and
professional development and to “look
forward and outward” towards N4K10 and
future professional practice upon graduation.
Meet with students in planned student-tutor
meetings and follow agenda items and
learning aims to help students meet learning
outcomes. Encourage students to draw on
previous experiences and personal strengths
and areas for growth and begin to help
students to shape their learning plan.
Maintain ongoing dialogue around learning
plan development and explore learning from
the “Entering Communities of Practice
“exercise
Provide McMaster or College email contact
information,
Student
•
•
•
•
•
•
•
•
•
•
within first two weeks of term.
Provide email contact information to the
learning triad.
Contact the professional practice tutor and
preceptor if you are involved in a medication or
treatment error or near miss at placement.
Follow the agency procedure and complete the
medication and or treatment error form/ see
link located on A2L.
If you are involved in an occupation health and
safety injury or incident seek first aid if needed,
follow the normal agency procedure. In
addition, fill out the University or College health
and safety form. The link to the form is located
on A2L Notify your preceptor and professional
practice tutor.
Discuss previous professional practice
experiences and feedback provided by previous
tutors to shape a progressive learning plan for
the term.
Recognize gaps in knowing, time management
and organization of learning, effective
participating in the interprofessional team and
intraprofessional team, and activate a plan for
learning.
Actively participate in the reciprocal dynamic
interactions between tutor-student and
preceptor-student
Engage in activities and discussions with tutor
and peers that support development of clinical
reasoning and clinical judgment; develop sense
of readiness for greater autonomy and
independence
Engage in student–tutor meetings and prepare
for each meeting (see learning sequence for
pre-planned agenda items.)
Attend student-tutor meetings prepared to
provide evidence of meeting course learning
outcomes and professional practice evaluation
criteria
Be prepared to discuss Community of Practice
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Professional Practice Tutor/Faculty
•
•
•
•
Discuss Community of Practice and CNO Code
of Conduct including all domains.
Discuss and explore critical reflections and
experiences in the practice setting as the term
evolves.
Complete tutor version of the Professional
Practice Evaluation Form at Midterm and Final
evaluation.
Assign Pass or Fail.
Student
•
•
•
•
•
•
•
•
•
•
including all domains.
Submit schedule planner; PP log at midterm and
final; reflections; learning plan and learning plan
evidence to drop box in A2L (see learning
sequence).
Ensure the PP log is signed by the preceptor
each shift.
Complete one CRW and one EIDM worksheet
and be prepared to discuss at student-tutor
meeting with peers and tutor.
Complete and be prepared to discuss learning
plan and reflections with peers and tutor at
student-tutor meeting.
Demonstrate clinical reasoning and judgment,
EIDM and multiple ways of knowing in
discussions.
Schedule Midterm and Final evaluation
meetings with Professional practice Triad
Complete the student version of the
Professional Practice Evaluation Form at
Midterm and Final evaluation and submit in
Drop Box on A2L.
Obtain and submit the preceptor’s version of
the Professional Practice Evaluation form at
midterm and final and submit to the A2L drop
box prior to the Triad meetings.
Demonstrate evidence of meeting learning plan
goals.
Complete Professional Practice Tutor
Performance form and Preceptor evaluation at
end of term
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Integration of Level 4 Professional Practice Concepts in Student-Tutor Meetings
Purpose:
•
•
To provide an in-depth educational focus for student-tutor discussion during
biweekly professional practice meetings.
To assist students in achieving N4K10 learning outcomes.
In Preparation for the Scheduled Group Student-Tutor Meeting:
Review agenda items for each student-tutor meeting (see Learning Sequence). Review
learning aims to prepare for discussion with peers and tutor for each meeting.
Table 1: Student-Tutor Meetings and Agenda Items N4K
Weeks (Wk) for
Student Groups
Meeting #1
Wk 2 (Group 1)
Wk 3 (Group 2)
Meeting #2
Wk 4 (Group 1)
Wk 5 (Group 2)
Meeting #3
Wk 6 (Group 1)
Wk 7 (Group 2)
Meeting #4
Wk 8 (Group 1)
Wk 9 (Group 2)
Meeting #5
Wk 10 (Group 1)
Wk 11(Group 2)
Meeting #6
Wk 12 (Group 1)
Wk 13 (Group 2)
Agenda Items
• Standing agenda items (Learning plan, PP log sheet, issues or
concerns)
•
Orientation expectations, Q&A specific to N4K; Group Norms; Review
Medication Administration; BScN Student Code of Conduct.
•
Community of Practice exercise
•
Clinical Reasoning Worksheet (CRW)
•
Evidence Informed Decision Making (EIDM) Work sheet
•
Role Transition: Resiliency to Prepare for Transition and Prevent
Transition Shock
•
Delegation
•
•
Learning Plan Evidence
Reflect on N4K-term/gaps to move to graduation
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Clinical Reasoning (CRW) and Judgment: Level 4 (Student-tutor meeting #3)
Description:
Registered Nurses are clinicians who provide safe, competent, ethical, compassionate, and
evidence-informed care across the lifespan in response to client needs. Registered Nurses
integrate knowledge, skills, judgment, and professional values from nursing and other diverse
sources into their practice (CNO, p.5)
Level 4 Clinical Reasoning and Judgment Learning Aims: Through self-directed readings and
tutor supported discussion learners will:
• Demonstrate understanding of clinical reasoning (noticing, interpreting, responding
and reflecting) to identify and prioritize patient issues, respond using a collection of
appropriate interventions that are guided by best evidence, safe practice,
professional standards, ethics, legislation, and personal and aesthetic ways of
knowing and reflect on / evaluate the care provided.
• Demonstrate understanding of therapeutic relationships with patients and families
through meaningful dialogue and humanistic caring approaches (CNO p.5)
Students use the Clinical Reasoning Worksheet (CRW) (Tanner, 2006) as an aid to enhance
learning and reflection from each professional practice day, and to promote clinical reasoning.
The worksheet is to optimize student understanding of clinical reasoning while gaining
familiarity with the context of the professional practice setting. Students are required to
complete at least one CRW in order to be prepared to discuss the CRW in the student-tutor
meeting with peers and tutor.
References:
Chinn, P., Krammer, M. (2008) Integrated theory and knowledge judgment in nursing. (7 th. Ed.),
Mosby Elsevier.
College of Nurses of Ontario (2019) Entry to Practice Competencies for Registered Nurses.
https://www.cno.org/globalassets/docs/reg/41037-entry-to-practice-competencies2020.pdf
Gillespie, M., (2010), Using the Situated Clinical Decision-Making framework to guide analysis of
nurses' clinical decision-making, Nurse Education in Practice.
https:/10.1016/j.nepr2010.02.003
Tanner, C. A., Benner, P., Chesla, C., Gordon, D.R. (1993). The phenomenology of knowing the
patient Image: Journal of Nursing Scholarship, 25 (4), 273-280.
Tanner, C.A. (2006) Thinking like a nurse: A research-based model of clinical judgment in
nursing. Journal of Nursing Education, 45(6), 204-211.
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Clinical Reasoning Worksheet (CRW)
Student Name: ____________________________
Clinical Week: _______
This is a learning aid for students and discussed in student tutor meeting. Students are expected to
complete one CRW for discussion in student-tutor meeting. Complete in 10pt font, single spaced,
bulleted summarized format; Remove prompters below if space is needed
Preparing for Professional Practice
Knowing the Case or Patient Population
What do I know (or need to know) about this patient population?
• What does the diagnosis mean? What is the underlying pathophysiology?
• How do patients with this problem/issue typically present (signs, symptoms, emotional
responses, difficulties, diagnostic test results)? What is the typical / usual clinical course?
• What types of treatments (including medications) are used and why?
• What is the nursing role in caring for patients with this problem / health challenge? What
types of assessment, communication, and psychomotor skills will I likely need to provide safe
and effective care for my patient? What are the treatment priorities and why?
During the Professional Practice Experience
Knowing the Individual . . .
As a Patient
As a Person
What makes my patient different What is my patient’s story (narrative)? How do (or might) my
from or the same as the “typical” patient’s past experiences with health & illness influence
cases? What is the “normal” (i.e., his/her responses to the pathophysiology, treatment, and
baseline) for my patient?
care? Are there other factors affecting my patient’s health or
response to care (i.e., age, social context, spirituality, personal
preferences etc.)?
Noticing – Gathering Cues & Information
You need to gather data/cues information from a wide variety of areas in order to thoroughly
determine the main issues that are affecting your patient. Look for the following information:
Chart Data
Treatment Plan
Admission note, medical history, report,
Medication record, code status, treatments (IV,
progress notes (various members of health
positioning, oxygen, diet, activity, dressings)
care team)
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Lab & Diagnostic Reports
What do these findings mean for this
patient?
Cues from my Patient
Patient’s perception of the situation (concerns, fears,
hopes, expectations, etc.); my own observations and
intuition about the patient’s needs
My Assessments (initial head to toe assessment; ongoing assessments during clinical shift)
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N4K10 Course Manual Winter 2022
Interpreting – Recognizing Patterns & Interpreting Data
Key Issues
Rationale
What are the most important issues for your patient? What are What subjective and objective
your nursing diagnoses? List at least 3 issues/nursing diagnoses. cues/assessments indicate that
these issues exist?
Responding – Determining a Course of Action
Nursing Actions/Interventions
What interventions would address the identified issue? List
3-4 interventions for each nursing diagnosis/issue.
Priority Level
What needs to be
attended to first and
why? Provide support for
your ranking.
Goals/Outcomes
What are the desired
short- and long-term
goals?
(Use SMART goals)
Priority Issue/Nursing Diagnosis #1:
Rationale
What are the reasons for my decisions
and actions? How does
literature/evidence support these
actions?
Goal:
Rationale:
Interventions:
1.
2.
3.
4.
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Priority Issue/Nursing Diagnosis #2:
Goal:
Interventions:
1.
Rationale:
2.
3.
4.
Priority Issue/Nursing Diagnosis #3:
Goal:
Interventions:
1.
Rationale:
2.
3.
4.
References:
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After the Professional Practice Experience (1/2 page / 1 paragraph max.)
Reflection – On Action and Clinical Learning
How did the nursing care plan meet my patient’s needs? Were outcomes/goals achieved? What were
my strengths today? What areas could I work on? What did I learn from my patient today? What did I
learn about myself? If I could repeat this day in clinical I would…
References
Gillespie, M., Using the Situated Clinical Decision-Making framework to guide analysis of nurses'
clinical decision-making, Nurse Education in Practice (2010),
https://doi:10.1016/j.nepr2010.02.003)
Tanner, C. A., Benner, P., Chesla, C., Gordon, D.R. (1993). The phenomenology of knowing the
patient. Image: Journal of Nursing Scholarship, 25 (4), 273-280.
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EIDM Worksheet: Level 4 (Student-tutor meeting #4)
Description:
Registered Nurses are Scholars who demonstrate a lifelong commitment to excellence in
practice through critical inquiry, continuous learning, application of evidence to practice, and
support of research activities. (CNO, p.8)
Level 4 EIDM Learning Aims: Through self-directed readings and tutor supported discussion
learners will:
• utilize Personal, aesthetic, emancipatory and ethical knowledge to inform clinical
reasoning and judgment and Evidence Informed Decision Making (EIDM) into
professional practice.
• utilize empiric knowing (generation, utilization, acquisition, translation, and transfer) to
inform clinical reasoning and judgment and Evidence Informed Decision Making (EIDM)
into professional practice.
• engage in EIDM self- reflection and competence (research skills, cultural humility,
nursing informatics, emerging evidence, and technologies, individual, community and
global health care issues) that contribute to lifelong learning. (CNO, p.8)
Students use the EIDM worksheet as an aid to help synthesize the evidence found and consider
barriers and facilitators to implementation in practice. Students are required to complete at
least one EIDM worksheet in order to be prepared to discuss EIDM n the student-tutor meeting
with peers and tutor.
Throughout Level 1 to Level 3, you have gained knowledge about how to develop
foreground questions, search for the best available evidence, critically appraise the best
available evidence, summarize the strengths and limitations of the evidence, interpret
and summarize the findings from the evidence, and make conclusions about whether the
evidence should be implemented in practice. In Level 4 PBL/PBL and Professional Practice,
you will continue to do the same while considering barriers and facilitators to
implementation in practice. Use the worksheet to help you synthesize the evidence you
find and consider barriers and facilitators to implementation in practice. In addition to the
Knowledge Translation EIDM online learning module and previous EIDM online learning
modules, exercises and assignments you have completed, additional resources are
provided below.
References:
Ciliska, R. B. Haynes, & Marks, S. (Eds.), Evidence-based nursing: An introduction. (pp. 244252). Blackwell Publishing, Ltd.
Graham, I. D., Logan, J., Tetroe, J., Robinson, N., & Harrison, M. B (2008). Models of
implementation in nursing. In N. Cullum, D. Ciliska, R. B. Haynes, & Marks, S. (Eds.),
Evidence-based nursing: An introduction. (pp. 231-243). Blackwell Publishing, Ltd.
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N4K10 Course Manual Winter 2022
O’Brien, M. A. (2008). Closing the gap between nursing research and practice. In N.
Cullum, D. Reardon, R., Lavis, J., & Gibson, J. (2006). From research to practice: A
knowledge transfer planning guide. Toronto Institute for Work & Health.
http://www.iwh.on.ca/from-research-to-practice
Registered Nurses Association of Ontario. (2002). Toolkit: Implementation of clinical
practice guidelines. Registered Nurse s Association of Ontario.
http://rnao.ca/sites/rnao-ca/files/BPG_Toolkit_0.pdf
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EIDM Worksheet: Level 4
My Question:
• Put your PICO/PS question in a
sentence
Where I Searched:
• At what level of the 6S Pyramid did
you find the evidence?
What I Found:
• What type of evidence?
Strengths & Limitations:
• Summarize strengths & limitations
identified through critical appraisal
Summarize the Findings:
In 2 to 3 sentences, summarize
• Were the findings statistically
(quantitative) and clinically
significant?
Implement “yes” or “no”?
• Consider “why”?
• Consider the EIDM Model
Plan for Implementation:
• What is the message?
• Who is the audience?
• Identify at least 1 barrier and 1
facilitator to implementation
• Identify 1 strategy for
implementation
• Identify 1 way you will know the
plan was effective?
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Transition: N4K10: Resiliency to Prepare for Transition and Prevent Transition Shock
(Student-Tutor Meeting #5)
Description: Role Transition
Transitions have been defined as passages or movements from one state, condition, or place to
another “which can produce profound alterations in the lives of individuals and their significant
others and have important implications for well-being and health” (Boychuk Duchscher, J. and
Windey, M. (2018).
Role Transition Learning Aims:
1. Explore new graduate nurses’ experiences with transition
2. Explore a transition model. For example, Boychuk Duchscher (2007).
3. Examine the concept of resiliency.
Required Readings:
Ang, S.A., Uthaman, T., Ayre, T., Lim, S.H., and Lopez, V. (2019). Differing pathways to
resilience: A grounded theory study of enactment of resilience among acute care.
Nursing & Health Sciences, 21(1), 132-138.
Benner, P (2000). From Novice to Expert in Clinical Practice. Prentice Hall.
Boychuk Duchscher, J. and Windley, M. (2018). Stages of transition and transition shock.
Journal for Nurses in Professional development. 34(4), 228-232.
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Delegation: Level 4 N4K10 (Student-Tutor Meeting #5)
Description: Delegation
Registered nurses are Collaborators who determines their own professional and
interprofessional role within the team by considering the roles and responsibilities and the
scope of practice of others. Registered nurses are Coordinators who demonstrate knowledge of
the delegation process (CNO 2019).
Delegation Learning Aims:
1.
Examine general concepts of delegation from a professional lens.
•
Definition
•
Difference between delegator and delegate
•
What it means to have authority to delegate
•
Documentation of delegation
2.
•
Examine concepts of delegation in Nursing
What is the Nursing “Five Rights of Delegation”?
•
Describe Controlled Acts Authorized to Nurses (Nursing Act, 1991) and authorizing
mechanisms needed before one can delegate
•
Describe the CNO Three-Factor Framework to assist in making effective decisions about
which nursing category (RN or RPN) to care-provider assignments
Required Readings:
Barrow, J. and Sharma, S. (2019). Nursing five rights of delegation. Stat Pearls[Internet].
https://www.ncbi.nlm.nih.gov/books/NBK519519/
CNO (n.d.). Delegation: An overview. http://www.cno.org/en/learn-about-standardsguidelines/educational-tools/ask-practice/delegation/
CNO (2018) Practice Guideline: RN and RPN Practice: The Client, the Nurse and the
Environment https://www.cno.org/globalassets/docs/prac/41062.pdf
CNO (2019) Entry to Practice Competencies for Registered Nurses.
https://www.cno.org/globalassets/docs/reg/41037_entrytopracitic_final.pdf
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Reporting Medication, Treatment Errors or Near Misses
Students are expected to let their Professional Practice tutor (and preceptor for L4 student)
know as soon as possible if they are involved in and/or observe a medication or treatment error
or near miss. If the incident is a critical incident the student is expected to notify their tutor
(and preceptor) on that shift. A critical incident is a serious injury to the patient or near miss.
The student and tutor arrange to meet as soon as possible if the incident is critical.
The student then:
1. Follows the normal agency procedure for follow-up and completion of the agency
incident or safety occurrence report.
2. Completes the university site specific online survey for the medication or treatment
error or near miss. This online survey is important to track errors and near misses,
analyze trends and recommend changes for improvement. Use one of the links below
specific to your site.
McMaster and Mohawk students: use this link
(http://fhsson.mcmaster.ca/limes/son/index.php?sid=38683)
Conestoga students: use this link (copy and paste)
(https://surveys.conestogac.on.ca/Blue/a.aspx?l=41_1_AAAAAAAAAX8).
Follow up will still be needed with your Professional Practise tutor. The student and tutor will
meet to debrief and consider individual and/or system issues, prevention strategies and any
further action follow-up. The tutor documents the notes from the debriefing meeting on a
Progress Record. The student signs the Progress Record and is provided with a copy.
Here is some specific information about medication errors for students.
Medication Administration–Safety Considerations (student-tutor meeting #1)
Standards: Administering Medications
Administering a medication is a continuous process and goes beyond the task of simply giving
medication to a patient. The nurse must apply their knowledge about the patient and the
medication when assessing, planning, administering, evaluating and documenting the process.
The same nurse must perform all the administration steps to minimize the chance of error and
clarify individual accountability. The standards for administration apply to prescription drugs as
well as other substances including over the counter medications and herbal preparations.
According to the CNO Medication (2019) Practice Standard, nurses must ensure appropriate
authority, competence, and safety during medication practices. Medication practices include
administration, dispensing, storage, inventory management, and disposal.
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•
•
•
•
Authority: Nurses must have the necessary authority to administer medications. This
includes appropriate, clear, and complete orders for controlled acts and all medication
practices.
Competence: Nurses must have the knowledge, skill and judgment to safely perform
medication practices. This includes using evidence-informed practices, assessing the
appropriateness of the medication practices for the specific situation
(client/medication/environment), knowing the limits of one’s medication competence
and seeking help as needed, and by not performing medication practices without proper
competence.
Safety: Nurses promote safe care and a culture of safety in the practice environment.
This includes seeking information from and providing education to clients about their
medication as needed, promoting and implementing appropriate storage,
transportation and disposal of medication, minimizing the risk of drug misuse and drug
diversion, resolving or minimizing the risk of client harm from a medication error or
adverse reaction, and reporting all medication errors, near misses and adverse events.
For more information on these 3 medication principles, please review the following:
https://www.cno.org/en/learn-about-standards-guidelines/educational-tools/decisiontool-medication/
Medication Administration Guidelines
Medication administration generally involves 3 broad categories: (1) Review of a medication
order; (2) deciding to administer medication and (3) deciding about dispensing. Each of these
actions involves a thoughtful consideration of multiple factors, such as the client’s health
history, other ordered medications, nursing knowledge of the medication, skills required to
administer it, and safe medication systems. Review each decision tree in the CNO medication
practice standard here:
https://www.cno.org/globalassets/docs/prac/41007_medication.pdf
https://www.cno.org/en/learn-about-standards-guidelines/educational-tools/decision-toolmedication/
Medication Administration–Safety Considerations
Medication errors are defined as any event that could lead to a patient receiving inappropriate
medication or failing to receive appropriate medication. Medication errors are the most
common type of error made by nurses. Medication errors can occur for a variety of reasons,
including failure to follow medication practice standards, administering unfamiliar medication,
neglecting to give an ordered medication, and failure to properly monitor and assess the
patient prior to medication administration. Nurses and learners are expected to protect clients
through recognizing and reporting near misses and errors (their own or others), and to take
action to stop and minimize harm arising from adverse events. A number of strategies can be
employed to increase safety in the medication administration process, including the use of
Tallman lettering, identification of high-alert medications, and use of independent doublechecks.
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Tallman Lettering
It is estimated that 1 out of every 1000 medication orders contain the wrong drug. Errors can
occur at different stages of the medication process, including prescribing, transcribing,
dispensing and administration. Contributing factors include similar names, similar product
labels, similar dosing and routes of administration. A variety of techniques are employed to
assist with differentiating between look-alike and/or sound-alike drug names. Tallman lettering
is one strategy to help differentiate among drugs with similar names. Tallman lettering may be
utilized on computerized medication ordering screens, automated pharmacy dispensing cabinet
systems, IV pump screens, standard order sets, and on medication labels. Understanding the
purpose of Tallman lettering is essential to ensure practitioners are aware of the purpose of
such lettering.
Tallman lettering highlights the differences between medications with similar names by
capitalizing the unique or dissimilar letters. In addition to capital letters, other methods of
emphasis, such as use of bold letters or a different colour, may also be used. This helps to draw
the health care provider’s attention to the drug name so that extra care and emphasis can be
taken to ensure the correct drug is being ordered or administered. Tallman letters are effective
in capturing attention, causing practitioners to pause, review the medication order, and to
ensure the drug is appropriate for the patient. Tallman lettering acts as a “visual alert system”
to ensure more care and attention is paid when verifying the medication to be given. In
addition to Tallman lettering, other medication safety strategies for look-alike/sound- alike
medications include using both the generic and brand names, including the reason for
administration with the medication order, storing similar sounding medications in separate
locations, and stocking different strengths or forms of similar sounding medications. For
example, to help distinguish between oxycodone and oxycontin, Tallman lettering would
appear as oxyCONTIN and oxyCODONE.
The Institute for Safe Medication Practices (ISMP) has created a list of look-alike/sound-alike
medications where Tallman lettering should be considered. The list is available at:
https://www.ismp.org/recommendations/tall-man-letters-list
Look-alike/sound-alike drug pairs can also be found on the ISMP’s List of Confused Drug Names:
https://www.ismp.org/recommendations/confused-drug-names-list
High Alert Medications
High alert medications are those that present an increased risk of significant patient harm,
should a medication error be made. The number of errors made with high-alert medications
may or may not be higher, but they have a higher potential to cause negative effects to patients
if an error occurs.
The ISMP has created a list of high-alert medications in acute care settings:
https://www.ismp.org/recommendations/high-alert-medications-acute-list
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Similar lists exist for high-alert medications in community/ambulatory care settings and longterm care. Common types of high-alert medications include antiarrhythmics, anticoagulants,
insulin, oral hypoglycemics, chemotherapy agents, Total Parenteral Nutrition solutions, and
narcotics/opioids. Medications on a high-alert list require stricter attention during
administration. As well, additional safety precautions to minimize the risk of errors, such as
improving access to information about these drugs, limiting health care provider access to highalert medications, using automated alerts, and employing independent double check processes
may also be put in place. Students must be aware of the list of high-alert medications in their
clinical agency, as well as any additional policies and procedures for ensuring medication safety,
such as independent double checks.
Independent Double Checks
In Canada, it is estimated that up to 23 750 Canadians die annually as a result of a preventable
adverse event (Baldwin & Walsh, 2014). Manual independent double checks for high-alert
medications are one widely used strategy to prevent potentially harmful medication errors
from reaching patients (ISMP, 2020). The use of independent double checks for high-alert
medications is supported by the ISMP, ISMP Canada and the College of Nurses of Ontario
(Baldwin & Walsh, 2014). Some studies have shown that independent double checks can detect
up to 95% of medication errors.
“Independent double checks must be implemented judiciously to minimize additional workload
for practitioners, and they must be carried out properly to be effective. A review of several
incidents reported to ISMP Canada raised concerns about practitioners’ understanding of the
differences between “double checks” and independent double checks, as well as concerns
about how these are performed. Practitioners may overlook the bias that can occur with double
checks that are not independent, or they may believe that double checking their own work is
enough to prevent medication errors”. (ISMP, 2019, p.4)
Incident Example: A nurse drew up insulin into a syringe for administration to a patient. A
second nurse was asked to verify the “10-unit dose”. The second nurse looked at the syringe
and agreed it was a 10-unit dose, although the dose drawn up was in fact double the intended
dose. ISMP Canada defines an independent double check as “a process in which a second
practitioner conducts a verification” such that “the first practitioner does not communicate
what he or she expects the second practitioner to see”. The goal is to limit any influence that
the first practitioner might have on the second practitioner and to eliminate confirmation bias
which can occur when the second practitioner is told by the first practitioner what to expect
and goes on to make the expected observation. Although the process can be carried out in the
presence or absence of the first practitioner, it is crucial that it remain independent and
asynchronous (i.e., the practitioners take on the task separately or alone)”.(ISMP, 2019, p.4)
“Here is an example of how the process might work: 1. The first practitioner asks a second
practitioner for a check and begins by explaining the verification needs (e.g., drug name and
dose). 2. The second practitioner performs the task required (e.g., checks drug name and dose),
but only after the first practitioner has completed the same task and without any further input
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from the first practitioner. 3. The results of the independent double check performed by the
second practitioner are then compared with the results obtained by the first practitioner to
determine any discrepancies”. (ISMP, 2019, p.4)
Therefore, to be most effective, the double check MUST be conducted independently by a
second person, where each person checks each step of the medication preparation process
separately. Health care practitioners completing the independent double check process must
not influence the checking process in any way. Research has demonstrated that other
healthcare professionals are better at detecting the errors of others than their own.
Independent double checks have been shown to be most effective when used judiciously for
selected high-alert medications. Students need to be aware of their agency’s policy and list of
medications where an independent double check is required.
Practitioners completing an independent double check should review the medication order &
administration decision trees. Nurses cannot assume that the medication or dose ordered is
correct and can be held accountable for giving a medication that was knowingly inappropriate.
When used properly, and in addition to other risk reducing strategies, independent double
checks can be an important patient safety strategy. The following table outlines specific
questions that should be addressed during an independent double check:
(ISMP, Independent double checks, 2013).
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Legal and Ethical Information Related to Administering Medications
Regulated Health Professions Act: Implications for Administering Medications
The legislation that sets the scope of nursing practice is the Regulated Health Professions Act
(RHPA) and the Nursing Act 1991. Both the RHPA and Nursing Act use a model that consists of
a series of authorized or controlled acts. The 14 controlled acts are activities that are
considered to be potentially harmful if performed by unqualified persons. Nurses are
authorized to perform five controlled acts when ordered or permitted by regulations under the
RHPA:
1. performing a prescribed procedure below the dermis;
2. administering a substance by injection or inhalation; and
3. putting an instrument, hand, or finger beyond a body orifice or artificial opening to the
body.
4. dispensing a drug
5. treating by means of psychotherapy
For more detailed information on the RHPA, please see:
rhpascope.pdf (cno.org)
For more detailed information on the Nursing Act, please see:
nursingact.pdf (cno.org)
Having the authority to administer medications does not necessarily mean it is appropriate to
do so. The context of the situation must be considered when assuming or allocating
administration responsibility, including complexity of the patient’s condition, the nurse’s
competencies and the practice environment.
Nurses and/or employers need to assess competencies to carry out their roles and
responsibilities safely and effectively in each situation, considering whether a nurse has:
• the knowledge, skill and judgement to fulfill the expectations outlined for administering
medications;
• the competence/resources required to intervene during an adverse reaction; and
• enough clinical practice opportunity to develop and maintain competence.
•
Controlled Substances
Nurses are responsible for following federal and provincial legal provisions when administering
controlled substances (drugs that affect the mind or behaviour). The Office of Controlled
Substances (OCS) of Health Canada regulates the distribution of controlled substances in
Canada, including those substances used by individuals and health care facilities for legitimate
scientific or health reasons. The program operates under the mandates of governing federal
legislation; for more information, please see:
https://www.canada.ca/en/health-canada/services/health-concerns/controlled-substancesprecursor-chemicals/controlled-substances.html
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Hospitals and other health care facilities have policies that outline the proper storage,
distribution, documentation, and disposal of controlled substances, including narcotics that you
are responsible for understanding prior to administering controlled substances.
The following is an example from the College of Nurses Standard (April 2019)
What would you do?
The following scenario demonstrates your accountabilities when you make a mistake in
practice.
Pat, a newly registered RN, recently started working in a stroke rehabilitation unit. During a
busy day shift, Pat accidentally gives amitriptyline to the wrong patient. Once Pat realizes her
mistake, she is horrified. She knows she did the necessary safety checks before administering
the medication. On review, she realizes that the patient shares a last name with another
patient on the unit, and she mixed up the patients. Pat monitors the patient closely. There are
no immediate adverse effects. Since the patient seems unharmed, Pat wonders if the health
care team, or the patient and their family, need to be informed. She is embarrassed about her
mistake and does not want to tell anyone. She is unsure what to do next.
A Commitment to Patient
Pat considers all the ways her mistake could affect the patient. She continues to closely monitor
the patient for adverse effects. She also thinks about her therapeutic relationship with the
patient. Pat knows that trust is at the core of a therapeutic relationship, and that lying or
omitting important information can irreparably damage that relationship. Pat realizes that in
order to maintain the therapeutic relationship, she must be honest with the patient and include
them as partners in their care. Pat knows that she must always put patients first. She realizes
that keeping her mistake secret in order to protect her professional reputation would be
putting her own needs before the needs of her patient.
A Commitment to Creating a Quality Practice Setting
Pat also reflects on why she made the mistake and the factors that led her to mix up the
patients. If she made this mistake, it is possible other members of the health care team might
as well. Pat realizes that in order to prevent a similar error from happening again, she needs to
speak up. She can advocate for her patients and provide them with the best possible care by
making sure no one else makes a similar mistake.
A Decision is Made
Pat tells her charge nurse about the mistake. Together, they discuss ways to prevent someone
else on the health care team from making a similar mistake. Pat also tells her charge nurse that
she has never had to disclose a mistake to a patient before. Pat realizes this is a learning need
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and asks for her charge nurse’s help. Together, they discuss the best way to inform the patient.
After disclosing the error to the patient, Pat reflects on the day’s events and her role in them.
She knows the error is an opportunity to learn. She thinks about her strengths, opportunities
for improvement and key learning needs.
Putting Patients First
When Pat disclosed her mistake to the team, she made the right choice to put her patient’s
needs ahead of her own. She was also advocating for a quality practice setting and ensuring
that future patients will receive safe care. By speaking up and putting her patient first, Pat was
upholding the principles in the nurses’ Code of Conduct and meeting her accountabilities
outlined in the Professional Standards, Revised 2002 and Medication practice standards. She
was also meeting her professional duty to report any error, behaviour, conduct or system issue
that affects patient safety.
Protecting Canadians from Unsafe Drugs Act (Vanessa's Law)
The Protecting Canadians from Unsafe Drugs Act (Vanessa's Law) amends the Food and Drugs
Act. It includes new rules that strengthen the regulation of therapeutic products and improve
the reporting of adverse reactions by healthcare institutions. As well, these measures are
intended to improve Health Canada’s ability to collect post-market safety information and take
appropriate action when a serious health risk is identified. The law is named after Vanessa
Young, daughter of the Member of Parliament from Oakville.
Protecting Canadians from Unsafe Drugs Act (Vanessa's Law) can be found on the Parliament of
Canada website. The Act applies to therapeutic products including prescription and over-thecounter drugs, vaccines, gene therapies, cells, tissues and organs, and medical devices. The
amendments brought to the Food and Drugs Act by Vanessa's law do not apply to natural
health products, which continue to be regulated under the existing Natural Health Product
Regulations (NHPR) of the Food and Drugs Act.
The Act increases patient safety in Canada by improving Health Canada's ability to collect safety
information on marketed therapeutic products and allows Health Canada to take quick and
appropriate action when a serious health risk is identified. These changes will lead to improved
patient safety and better health outcomes for Canadians, including vulnerable populations such
as children, seniors, and pregnant or nursing women.
See Q and A in the link below included under references.
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References
Baldwin, K. & Walsh, V. (2014). Independent double-checks for high-alert medications: Essential
practice. Nursing, April 2014, 44(4), 65-67.
College of Nurses of Ontario. (2019). Entry to practice competencies for Registered Nurses.
https://www.cno.org/globalassets/docs/reg/41037-entry-to-practice-competencies2020.pdf
College of Nurses of Ontario. (2019). Practice Standard: Medication.
https://www.cno.org/globalassets/docs/prac/41007_medication.pdf
Institute for Safe Medication Practices. (2019). ISMP Canada Safety Bulletin: Independent
Double Checks – Are Your Checks Truly Independent?
https://www.ismp-canada.org/news/item/396/
Institute for Safe Medication Practices. (2020). FDA and ISMP Lists of Look-Alike Drug Names
with Recommended Tall Man Letters.
https://www.ismp.org/recommendations/tall-man-letters-list
Institute for Safe Medication Practices. (2020). ISMP’s List of Confused Drug Names
https://www.ismp.org/recommendations/confused-drug-names-list
Institute for Safe Medication Practices. (2020). ISMP List of High-Alert Medication in Acute Care
Settings.
https://www.ismp.org/recommendations/high-alert-medications
Institute for Safe Medication Practices. (2013). Independent double checks: Undervalued and
misused.
https://www.ismp.org/resources/independent-double-checks-undervalued-and-misusedselective-use-strategy-can-play
Kaasalainen, S. (2014). Medication administration. In J.C. Ross-Kerr, M.J. Wood, B.J. Astle, &
W. Duggleby (Eds.), Potter and Perry Canadian Fundamentals of Nursing (5th ed., (pp.
662-750). Elsevier.
Perry, A., G., Potter, P., A., & Ostendorf, W., R. (2018). Clinical nursing skills & techniques (9th
ed.) Elsevier.
Protecting Canadians from Unsafe Drugs Act (Vanessa's Law) Amendments to the Food and
Drugs Act (Bill C-17)
Additional Resources
College of Nurses of Ontario
• Practice Standards
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o Documentation
o Decisions about Procedures and Authority
• Legislation and Regulation
o RHPA-Scope of Practice, Controlled Acts Model
o
Institute for Safe Medication Practices www.ismp-canada.org/
Insulin Pen How-to:
Diabetes Canada (March 19, 2019). Insulin & You: A guide to injecting insulin [Video file].
https://Diabetes.ca/managing-my-diabetes-/webinars/how-to-inject-insulin-a-step-bystep-guide
American Association of Diabetes Educators (April 23,2021). Insulin injection how to
https://diabeteseducator.org/docs/default-source/legacydocs/_resources/pdf/general/Insulin_Injection_How_To_AADE.pdf
The following is an example from the College of Nurses Standard (April 2019)
What would you do?
The following scenario demonstrates your accountabilities when you make a mistake in
practice.
Pat, a newly registered RN, recently started working in a stroke rehabilitation unit. During a
busy day shift, Pat accidentally gives amitriptyline to the wrong patient. Once Pat realizes her
mistake, she’s horrified. She knows she did the necessary safety checks before administering
the medication. On review, she realizes that the patient shares a last name with another
patient on the unit, and she mixed up the patients. Pat monitors the patient closely. There are
no immediate adverse effects. Since the patient seems unharmed, Pat wonders if the health
care team, or the patient and their family, need to be informed. She’s embarrassed about her
mistake and doesn’t want to tell anyone. She’s unsure what to do next.
A commitment to patient
Pat considers all the ways her mistake could affect the patient. She continues to closely monitor
the patient for adverse effects. She also thinks about her therapeutic relationship with the
patient. Pat knows that trust is at the core of a therapeutic relationship, and that lying or
omitting important information can irreparably damage that relationship. Pat realizes that in
order to maintain the therapeutic relationship, she must be honest with the patient and include
them as partners in their care. Pat knows that she must always put patients first. She realizes
that keeping her mistake secret in order to protect her professional reputation would be
putting her own needs before the needs of her patient.
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A commitment to creating a quality practice setting
Pat also reflects on why she made the mistake and the factors that led her to mix up the
patients. If she made this mistake, it’s possible other members of the health care team might as
well. Pat realizes that in order to prevent a similar error from happening again, she needs to
speak up. She can advocate for her patients and provide them with the best possible care by
making sure no one else makes a similar mistake.
A decision is made
Pat tells her charge nurse about the mistake. Together, they discuss ways to prevent someone
else on the health care team from making a similar mistake. Pat also tells her charge nurse that
she has never had to disclose a mistake to a patient before. Pat realizes this is a learning need
and asks for her charge nurse’s help. Together, they discuss the best way to inform the patient.
After disclosing the error to the patient, Pat reflects on the day’s events and her role in them.
She knows the error is an opportunity to learn. She thinks about her strengths, opportunities
for improvement and key learning needs.
Putting patients first
When Pat disclosed her mistake to the team, she made the right choice to put her patient’s
needs ahead of her own. She was also advocating for a quality practice setting and ensuring
that future patients will receive safe care. By speaking up and putting her patient first, Pat was
upholding the principles in the nurses’ Code of Conduct and meeting her accountabilities
outlined in the Professional Standards, Revised 2002 and Medication practice standards. She
was also meeting her professional duty to report any error, behaviour, conduct or system issue
that affects patient safety.
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What Can Students Do?
Students have many learning opportunities in the clinical setting that include carrying out a
variety of nursing skills or interventions or nursing actions. Students and preceptors sometimes
wonder if the student can carry out the ‘skill’. The following questions and resources will assist
the students and preceptors in the decision-making and facilitate the student’s knowledge
development regarding key documents from the College of Nurses of Ontario and related
government legislation that form the foundation of professional nursing practice.
The CNO’s nursing scope of practice describes the procedures, actions and processes nurses are
qualified to perform according to current legislation, the practice environment and individual
competence. A question CNO frequently receives from nurses is whether an activity falls within
their nursing scope of practice. If you are unsure if a specific activity is within your scope of
practice, you must consider and answer yes to the following three questions before you
proceed:
1. Is the activity within your legislative scope?
Nurses are accountable to practice under relevant legislation, such as the Nursing Act, 1991 and
the Regulated Health Professions Act, 1991. Depending on your practice setting, you also may
be accountable to other legislation, such as the Public Hospitals Act or the Long-Term Care
Homes Act, 2007.
2. Is the activity supported by your employer and practice setting?
Employers are responsible for determining the roles and responsibilities of their employees,
including determining whether nurses can perform certain activities and procedures in the
practice setting. You are encouraged to consult with your employer and the health care team to
determine if your practice setting supports the performance of the activity.
3. Do you have the knowledge, skill, and judgment to perform the activity?
Prior to performing any activity, you are accountable for reflecting on your individual scope and
considering whether you have the adequate knowledge, skill, and judgment to perform the
activity or procedure safely and competently.
If you respond no to one of these questions, the activity may not be appropriate. You should
review the relevant practice standard, or contact CNO’s Practice Support team. You can also
consult with your employer and the health care team.
To help you further reflect on each of the three questions, read Understanding Your Scope of
Practice in Ask Practice for more guidance.
When carrying out a nursing skill/action, the student should ask him or herself the following
questions and refer to the identified resources. If the response to any of the following
questions is “no”, then the student should discuss the decision with the preceptor and/or tutor.
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1. Is this skill/intervention/nursing action within my scope of practice?
Resources:
• Nursing Act (1991): https://www.ontario.ca/laws/statute/91n32
• College of Nurses of Ontario Legislation and Regulation. RHPA: Scope of Practice, 4
Controlled Acts Model (2014):
https://www.cno.org/globalassets/docs/policy/41052_rhpascope.pdf
2. Do I have the knowledge, skill, and judgment (and authority) to carry out this
skill/intervention? (A note: the language here is left ‘knowledge, skill and judgment’
because it is usually what the student encounters in the clinical setting with their preceptors
and other care providers)
Resources:
• College of Nurses of Ontario National Competencies in the Context of Entry-Level
Registered Nurse Practice Adopted for Ontario Registered Nurses Entry-to-Practice
Competencies, Revised 2019 to start Sept. 2020.
(http://www.cno.org/globalassets/docs/reg/41037_entrytopracitic_final.pdf )
• College of Nurses of Ontario Practice Guidelines: Supporting Learners (2017), Pub.
No. 44034
3. Does the clinical agency policy support BScN student nurses in carrying out this
skill/intervention/nursing action?
Resources:
• Check agency policies – many agencies have specific guidelines for student nurses
• Unit Educator, Unit Manager, Clinical Preceptor
4. Does this skill/intervention/nursing action fit with the learning outcomes? With my
personal learning goals/needs?
Resources:
• BScN Handbook, Course syllabus, Clinical preceptor, professional practice tutor,
Learning plan
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Figure 1: Conceptual framework for organizing competencies
Glossary of Terms for Registered Nurse’s Roles
This is taken from the CNO Entry to Practice Competencies, which take effect in September of
2020.
http://www.cno.org/globalassets/docs/reg/41037-entry-to-practice-competencies2020.pdf
1. Clinician
“Registered Nurses are clinicians who provide safe, competent, ethical, compassionate,
and evidence-informed care across the lifespan in response to client needs. Registered
Nurse s integrate knowledge, skills, judgment and professional values from nursing and
other diverse sources into their practice” (CNO, p.5)
2. Professional
“Registered Nurses are professionals who are committed to the health and well-being of
clients. Registered Nurse s uphold the profession’s practice standards and ethics and are
accountable to the public and the profession” (CNO, p.5)
3. Communicator
“Registered Nurses are communicators who use a variety of strategies and relevant
technologies to create and maintain professional relationships, share information, and
foster therapeutic environments” (CNO, p.6)
4. Collaborator
“Registered Nurses are collaborators who play an integral role in the health care team
partnership” (CNO, p.6)
5. Coordinator
“Registered Nurses coordinate point-of-care health service delivery with clients, the
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6.
7.
8.
9.
health care team, and other sectors to ensure continuous, safe care” (CNO, p.7)
Leader
“Registered Nurses are leaders who influence and inspire others to achieve optimal
health outcomes for all” (CNO, p.7)
Advocate
“Registered Nurses are advocates who support clients to voice their needs to achieve
optimal health outcomes. Registered Nurse s also support clients who cannot advocate
for themselves” (CNO, p.7)
Educator
“Registered Nurses are educators who identify learning needs with clients and apply a
broad range of educational strategies towards achieving optimal health outcomes”
(CNO, p.8)
Scholar
“Registered Nurses are scholars who demonstrate a lifelong commitment to excellence
in practice through critical inquiry, continuous learning, application of evidence to
practice, and support of research activities” (CNO, p.8)
References
College of Nurses of Ontario [CNO] (2019). Entry-To- Practice Competencies for Registered
Nurses.
https://www.cno.org/globalassets/docs/reg/41037-entry-to-practice-competencies-2020.pdf
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Submission of Grades and Evaluation Forms
The Professional Practice (PP) Tutor will publish the midterm evaluation form for the
student at midterm. At the end of the course, the Professional Practice Tutor will publish
the final evaluation form for the student, submit the final grade (Pass/Fail) and total hours
completed on Avenue to Learn (A2L). The following forms are submitted on A2L:
•
•
•
•
•
The Professional Practice (PP) Log of Clinical Hours signed by preceptor (student
submits at midterm and final in drop box on A2L.
The Professional Practice Midterm & FINAL self-Evaluation Form for STUDENT
(student submits at midterm and final in drop box on A2L)
The Professional Practice Midterm and FINAL Evaluation Form for PRECEPTOR
(student submits at midterm and final to drop box labeled as Preceptor Dropbox on
A2L prior to the Triad Meeting)
The Professional Practice Midterm and FINAL Evaluation Form for TUTOR (tutor
uploads and publishes at midterm and final on A2L in student drop box)
Progress Record if applicable. (Tutor uploads and publishes on A2L in student drop
box)
Professional Practice Tutors submit grades to A2L,
and total hours completed.
It is very important to identify any major problems in professional practice performance
and/or the evaluation process by mid-term. Students should seek help early in the term
from the Preceptor and Professional Practice Tutor.
The Level 4 Lead/Coordinator should become involved if problems cannot be resolved by
the Professional practice Tutor and/or if further information and advice is required.
The level 4 Lead for McMaster is Alida Bowman, the Coordinator for Mohawk Priscilla
Patterson, and Susanne Bush for Conestoga. (See contact information in Course Outline)
Students providing feedback to the Professional Practice Tutor and Preceptor
The student is encouraged to provide feedback to both the Professional Practice Tutor and
the Preceptor on their performance. The process is as follows:
(1) Tutor evaluation and course evaluations will be completed online. More
information on this process will be provided on Avenue as the end of term
approaches.
(2) Preceptor evaluation is intended for the Preceptor’s personal use and should be
given directly to the preceptor. The preceptor’s name and setting are to be
identified on the preceptor evaluation form. Do not submit to the course planner
or Professional practice Tutor. The form is available on Avenue to Learn.
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