SUNY Delhi

MS in Nursing Education
NURS 604/605 Graduate Advanced Clinical Practicum Learning Contract

Practicum Focus:
The focus of this practicum
I have planned two separate clinical experiences for this practicum. The first is attendance as a volunteer Registered nurse at
Remote Area Medical (RAM) In Knoxville, TN.
I expect that through this experience I will have:
A greater understanding of medical access issues for the underserved indigent populations served by RAM.
Identified actual and/or potential roles for the advanced practice registered nurse (APRN) in the RAM setting, and also
the
Identified actual and/or potential roles for the APRN in underserved areas with indigent populations.

The second clinical experience is shadowing Arlene Walch, Clinical Nurse Educator (CNE) at Columbia Memorial Hospital.
I plan to:
Identify learning needs and/or knowledge deficits of CGCC graduate nurses.
Identify three teaching and learning activities to be potentially integrated into CGCC nursing program theory or clinical
curriculum to address these deficits.
Identify three responsibilities of the Arlene Walch in her role as CNS at CMH.

A B C Practicu
Outcomes for Each Week Learning Activities to Evidence of Accomplishments to Meet m Hours
in the Practicum Setting Accomplish Weekly Outcomes
Outcomes

Week 1 Phone call with faculty Completed LC submitted to faculty by Friday of Week Week 1
Outcome 1: The student will (preceptor included if Cumulative
communicate with faculty desired). Practicum
and preceptor in order to Total
begin to formulate practicum Meet with preceptor. Hours:
plan and goals. Prepare and submit
Learning Contract.

Weeks 2-4
Outcome 2: The student will
attend Remote Area Medical
(RAM) in Knoxville, TN and
upon completion of clinical
hours, will have identified 3
medical access issues for
underserved indigent
populations.
Outcome 3: The student will
attend RAM, and upon
completion of clinical hours,
will have identified 3 actual
or potential roles of the
Advanced Practice
Registered Nurse (APRN) in
this setting.
(Outcomes 2, 3, 4) Attend Create VoiceThread presentation introducing RAM, outlining Weeks 2-
Remote Area Medical (RAM) issues in regard to medical access for underserved, indigent 4
IN Knoxville, TN. populations, presentation of actual or potential roles of the Cumulati
(Outcome 3) Observe and/or APRN in the RAM and remote/rural healthcare settings. ve
interview APRN in the RAM Presentation to include live video clips of area and/or Practicu
setting to identify actual or population to be served, APRNs at work or being m Total
potential roles in this setting. interviewed, only as time and HIPPA/RAM policy allows. Hours:
(Outcomes 3, 4) First-hand 33
observation and assessment of
geographical area, APRNs in
RAM setting, and additional
research to be done after RAM
experience.

Outcome 4: The student will

attend RAM, and upon
completion of clinical hours
and additional research,
identified 3 possible roles for
the APRN in underserved
areas with indigent
populations.

D: Activities, Evidence, and Outcomes (Weeks 1-4)

Activities completed:
What activities were D1: Practicum Activities
proposed versus what
activities did you There are two components of my practicum experiences. The first was my participation
actually complete? in the Remote Area Medical (RAM) in Knoxville, and the second will be to shadow Arlene
Evidence: Provide a Walch, the clinical nurse educator at Columbia Memorial Hospital in Hudson, NY.
 bulleted list of
evidence of activities I attended the RAM clinic in Knoxville, Tennessee with Dr. Kirsty Digger and a number of
completed and attach fellow MSN classmates. The clinic took place on the weekend of February 4-5. On the
evidence files in first day at RAM, I was stationed at the intake desk for the medical exam area. The
dropbox with learning
primary responsibility in this role was to review patients medical forms to be sure they
contract (up to 5 files)
were complete, and that the consents were signed. On the second day, I worked at a
Outcomes: What
triage table taking vital signs, histories, and other pertinent information from clients.
outcomes were met,
how were they met,
and if not met, provide The activities that I proposed were to attend RAM, and to observe and/or interview
insight. advanced practice registered nurses (APRN) in the RAM setting, and in the surrounding
geographical area Knoxville in order to identify three actual or potential roles of APRNs
in these settings. In addition, I also planned that through participation in RAM, I would
also be able to identify three medical access issues for the underserved and indigent
populations in this area.

I had hoped to have more of a chance to look more closely at the Knoxville area in order
to help me meet my outcomes. However, my ability to do so was limited by both
transportation and time constraints. I also had hoped to have live video clips of
interviews with practitioners, but the setting did not lend itself to this. However, I was
able to take a number of photos, which I think will give a good sense of the setting.
However, the RAM clinic provided more than ample opportunities to interview patients,
providers, and volunteers. In so doing, I was able to meet my outcomes, as all of the
information I needed was provided by these individuals, and through my observations at
the clinic.

D2:Evidence

VoiceThread Presentation
RAM assignment designation
(see dropbox)

D3: Outcomes

Outcome 1: The student will communicate with faculty and preceptor in order to begin
to formulate practicum plan and goals.

In these first 4 weeks of class, I arranged shadowing experiences to take place with
Arlene on Friday, Feb 17 and Monday, Feb 20. In addition to phone, email, and face-to-
face meetings with Arlene, my learning contract was developed for both practicum
experiences (RAM and CMH with Arlene Walch) and signed. My work with Arlene will be
presented in the weeks 5-7 learning contract assignment. The planning of these
activities and the development of the learning contract met outcome 1 for this
practicum.

Outcome 2: Identify three medical access issues for the underserved indigent
populations.

1. Transportation to services is difficult, especially for those individuals in rural areas where public
transportation was not available.
2. Available appointment times were inconvenient as many individuals had jobs (many had multiple jobs)
with schedules that did not allow them to make normal appointment times for medical care.
3. Many individuals had incomes just above the poverty line, which prevented their eligibility for
Medicaid. If these individuals did have insurance, co-pays were prohibitively expensive, both for office
visits, and prescriptions.
4. There were volunteer translators at RAM. However, for many of the patients served at RAM and in the
community, language barriers stood in the way of their receiving medical care in the community. Not
only did these language barriers stand in the way of patients when they received care from providers,
the language barriers contributed to disenfranchisement, further contributing to underutilization of
available services as well.

Outcome 3: Identify three actual or potential roles of the APRN in the RAM setting.

1. Nurse practitioners saw patients in the medical area of RAM, and provided a wide range of assessments
and interventions. Procedures were done, diagnoses made, referrals given, and prescriptions were
written for a variety of patient complaints.
2. The coordinator of the medical area of RAM was a nurse practitioner. Joe S. was a pediatric nurse
practitioner with extensive RAM clinic experience. Joe S. coordinated providers, nursing, and other
staff in the care of patients. With the intake, triage nurses, Joe S. was also responsible for assessing the
patients chief complaint in order to direct individuals to the most appropriate provider. In addition, he
cared for a number of pediatric patients as well.
3. Nursing educators were present in abundance at RAM. These educators oversaw their nursing students
who were serving as volunteers at the RAM clinic.

Outcome 4: Identify three actual or potential roles of the APRN in underserved

areas with indigent populations.
 1. As mentioned earlier, one of the big issues for patients was access to medical care, whether as a result
2. I can also most definitely see a role for nurse practitioners as health educators in the community. So
3. There is also great potential for nurse educators in serving the underserved and indigent populations.
Weeks 5-7
Outcome 5: The student will
identify 3 learning
needs/knowledge deficits of
Columbia Greene Community
College (CGCC) graduate
nurses (GN) hired by
Columbia Memorial Hospital
(CMH).
Outcome 6: The student will
identify 3 teaching and
learning activities to be
potentially integrated into
CGCC nursing program
theory or clinical curriculum
of transportation issues, or inability to take time off from work to attend clinics. Populations with
challenges such as these would be well-served by nurse practitioner primary care clinics brought to
remote communities and/or workplaces. Not only would bringing such care to communities increase
access, but holding hours that fall outside normal office visit hours would be invaluable as well.
many of the disease processes and issues faced by the patients we saw were as a result of impaired
health maintenance. Many of these issues could prevented by some fairly basic education in regard to
disease prevention. Such areas as drug and alcohol use and its implications, smoking cessation, dental
health, STD prevention, women and childrens health, the importance of vaccinations, and management
of chronic diseases such as diabetes would go a very long way to improving quality of life for so many
of the individuals we saw. I think that APRNs could serve in educational, research, and coordination
roles for services and in obtaining the resources to provide them.
Bringing students to events like RAM, and clinics held in underserved areas, would not only help to
serve a population in need, and to hone students skills, it would also expose students to an experience
that in many cases will energize, motivate, and mobilize these students to make volunteer work an
integral part of their practice. The importance of exposing such students to service opportunities such
as RAM cannot be underestimated, as such work is not only vital, but will add an unparalleled
dimension and depth to the students lifelong practice and service to others.
(Outcomes 5, 6, 7) Shadow Create VoiceThread presentation discussing learning the Weeks 5-
Arlene Walch, (Clinical identified learning needs/knowledge deficits of CGCC 7
Nurse Educator) Columbia GNs hired by CMH. Cumulati
Memorial Hospital, Hudson, Presentation will also include discussion of learning ve
NY. activities that might be created and integrated into Practicu
(Outcomes 5, 6, 7) CGCC nursing program theory or clinical curriculum to m Total
Discussion, interviews, and address these learning needs/knowledge deficits. Hours:
observation of/with Arlene Finally, discussion of the role of the CNS in the hospital 17.25
Walch, other clinical setting as executed by Arlene Walch in her work at
educators, floor managers, CMH.
preceptors, and graduate
nurses.
(Outcome 6, 7) Observe and
interview CNE Arlene
Walch in hospital setting in
to address identified learning
needs/knowledge deficits of
CGCC graduate nurses.
Outcome 7: The student will
identify 3 responsibilities of
the Clinical Nurse Educator
(CNE) at CMH.
her role as CNE.
(Outcome 7) Interview floor
managers, GNs, other
hospital staff, and leadership
in regard to their perceptions
and experiences of Arlene
Walchs role as CNE.

D: Activities, Evidence, and Outcomes (Weeks 5-7)

Activities completed: D1: Practicum Activities

What activities were
proposed versus what For the second component of my practicum experience I engaged in a number of
activities did you activities. The first was to shadow Arlene Walch, the clinical nurse educator (CNE) at
actually complete? Columbia Memorial Hospital (CMH) in Hudson, NY. During this shadowing experience I
Evidence: Provide a engaged in discussion, interviews, and observation of Arlene, other clinical educators,
bulleted list of floor managers, preceptors and graduate nurses.
evidence of activities
completed and attach
evidence files in Shadowing Arlene was an extremely interesting and diverse experience. As I suspected,
dropbox with learning Arlene inhabits a multitude of roles at the hospital, and I was able to see her at work in
contract (up to 5 files) many of them. One extremely valuable and unexpected experience was accompanying
Outcomes: What Arlene to a teaching day at the Capital District Critical Care Consortium (CDCCC). At this
outcomes were met, consortium, I was able to observe Arlene in the role as educator of attendees, and also
how were they met, as preceptor to a CNE from St. Peters Hospital in Albany, NY who was lecturing at the
and if not met, provide consortium for the first time. Throughout this day, I was not only able to observe Arlene
insight. at work, but had ample opportunity for discussion in regard to her multifaceted role.
Accompanying Arlene to the CDCCC was an extremely valuable learning opportunity.

I also shadowed Arlene in her work at CMH. I was able to observe her at the CMH daily
safety meeting, in consultation with the informatics specialist for the hospital, and in the
running and coordination of the education office in many of its daily duties, including a
training for new hires.

Finally, I was also afforded the opportunity to interview floor managers, staff nurses, the
CMH informatics specialist, and Columbia Greene Community College (CGCC) graduates
working at CMH. My interviews with many of these contacts continued via email, phone
calls, and additional brief meetings, as I sought clarification and deeper understanding
as I gathered information. This was an extraordinarily valuable and productive time-
period which I am certain will influence my work at CGCC.

D2: Evidence

Narrative of experiences: In place of previously proposed VoiceThread

Screencast-O-Matic link (in narrative of experiences)
Critical Care Consortium Schedule
CMH documents for training new graduates/hires: (Weekly learning needs assessment/evaluation of
orientee, Initial RN skills checklist, IV Pump competency, Peripheral IV competency)
RRT SBAR, and SBAR report forms
(see dropbox)

D3: Outcomes

Outcome 5: The student will identify 3 learning needs/knowledge deficits of Columbia

Greene Community College (CGCC) graduate nurses (GN) hired by Columbia Memorial
Hospital (CMH).

These learning needs were garnered from interviews with Arlene Walch, floor managers,
staff nurses, graduate nurses, and the informatics specialist.

1. Because of the inability of students from CGCC to document on the computers at CMH, the learning
curve for computer documentation has been found to be quite high for new graduates. Barriers to
students being able to document on computers during nursing school include: lack of time, training,
and lack of adequate numbers of computers. At present, nursing students only use the hospital
computers for medication administration, and for gathering patient data during research and clinical
time.

2. One of the areas all of the interviewees mentioned as a stumbling block was the ability to give
thorough, rapid accurate, and concise shift-to-shift, nurse-to-physician, and nurse-to-other collaborative
disciplines (such as that necessary in a rapid response of code situation) report. This is not an area in
which students have a great deal of practice, especially in the realm of speaking with providers and
other team members in an emergency situation.

3. CMH nurses charting by exception (CBE), where CGCC students are taught to write comprehensive
narrative notes. Many of the interviewees raised concerns that CBE was not well done by floor nurses
or new graduates, and that episodic narrative notes were rarely written, even when necessary. Almost
all of the interviewees traced the new graduates difficulty with this to an initial lack of familiarity (and
 slowness) with the system. This initial lack of familiarity presented time constraints, and it is thought
that bad documentation habits have developed as a result.

4. Finally, many managers, staff nurses, and new graduates mentioned a lack of understanding as to what
the ongoing expectations were for new hires, both during orientation and afterward. Both preceptors
and new hires expressed concern about this in the realms of both consistency and understanding.
Although there is a training, competency, and evaluation structure in place, there are a number of
stumbling blocks such as changing preceptors, departments, and managers during the orientation
process. Although most new graduates remain on the same floor for their orientation, the preceptors are
often changed as a result of scheduling and other issues. However, new graduates hired into critical
care areas (e.g. ICU, OR, ED), are rotated throughout departments in the hospital, and often find a lack
of consistency and continuity in their training. All of the interviewees (even the GNs themselves)
identified the inability to self-advocate and follow-through as components of this concern.

Outcome 6: The student will identify 3 teaching and learning activities to be potentially
integrated into CGCC nursing program theory or clinical curriculum to address identified
learning needs/knowledge deficits of CGCC graduate nurses.

1. In discussion with Arlene and the informatics specialist Al Sardino, I had occasion to share my
rudimentary trial, in which I used Screencast-O-Matic to capture the computer screen in the CMH
education computer lab. Both Arlene and Al were very enthusiastic about this software, and could see a
definite application for its use. Both Arlene and Al mentioned Captivate and Articulate software, but
their previous forays into looking at these products were not productive. What they especially liked
about Screencast-O-Matic was its ease of use, the fact that it was web-based (eliminating the need for a
security-laden download), and its price. In the future, I will be working with Arlene and AL to create
teaching tools using the Screencast-O-Matic software for both CGCC students and new hires at CMH.
(Please see Screencast-O-Matic link in
evidence narrative)

2. In order to address new graduates difficulty in giving thorough, rapid, accurate, and concise report, I
plan to develop an exercise to be done in class to hone this skill. My tentative plan is to have students
role play the parts of patient, nurse, provider, and other collaborative team members, and to use an
SBAR report form and structure to give effective report to team members. Although students give
SBAR report at present in clinical pre-conference, this is much less pressured than in a live clinical
situation. The faculty at CGCC have expressed an interest in reinforcing the honing of this skill in the
clinical setting as well.
(Please see RRT SBAR, and
SBAR report forms)
 3. In regard to the documentation issues identified by the interviewees, as part of my lecture content I
intend to review the principles and responsibilities associated with the use of CBE with my students. I
will also reinforce the necessity of narrative notes in particular situations the students might face as
nurses. In addition, it is my hope that the Screencast-O-Matic teaching tools I create for and with CMH
will help the students, and ultimately the new graduates, use the CMH computer system with a less
daunting learning curve in order that they might be able to be up-to-speed more quickly, and less apt to
develop bad documentation habits once in the clinical setting.

4. In regard to graduate nurses issues in regard to lack of consistency and continuity with training, there
are a couple of ways I would like to address this. First, I plan to reinforce the idea of professional
responsibility. Although we already cover this topic in class, I think that real-world examples and
presentation of the issues seen at CMH might be helpful in students understanding. In addition, the
idea of professional responsibility in regard to self-advocacy (especially in the realm of training needs)
will be reinforced as well. With Arlene Walchs permission, I plan to share the hospitals documents for
graduate nurse orientees (weekly learning needs assessment/evaluation of orientee, initial RN skills
checklist, IV Pump competency, Peripheral IV competency), in order to help highlight the processes the
students will participate in upon hire, and to encourage them to be proactive in seeking out necessary
learning opportunities, and remediation for any roadblocks they may face. Many of the new graduates I
spoke with felt that they had been unaware, or even too passive, in regard to their orientation. It is my
hope that these classroom discussion and materials will help to mitigate this issue.
(Please see CMH documents for training new
graduates/hires)

Outcome 7: The student will identify 3 responsibilities of the Clinical Nurse Educator
(CNE) at CMH.

As mentioned earlier, Arlene Walch has a wide range of responsibilities in her

multifaceted role at CMH. The following represent just a small sampling of Arlenes
many responsibilities.

1. Arlene is responsible for the training of all registered nurse and personal care assistants at CMH. She
creates training materials In Healthstream (online education program) oversees and conducts classroom
experiences, and plans and oversees new hires orientation in the clinical setting. Arlene is also one of
the primary hospital and community educators for BLS, CPR, and ACLS as well.

2. As part of her responsibility for training, Arlene works with the Capital District Critical Care
Consortium (CDCCC). Each participating facilitys representative has a 50 hour teaching obligation, as
 well as the responsibility to participate in a service. Currently, Arlene lectures on tissue issues,
gastrointestinal assessment, gastrointestinal bleeding, hepatic failure, pancreatitis, bowel obstruction,
and nutrition for the acutely ill. Her present service responsibility (usually a two-year obligation) is
overseeing and producing CDCCC curriculum updates. As a result of Arlenes participation in the
CDCCC, nurses from CMH are able to participate in the CDCCC free of charge.
(Please see Critical Care
Consortium Schedule)

3. At CMH, Arlene is also responsible for writing and revising hospital policies. She is also responsible
for assuring that the facility is current in the proper use of new equipment, and also current with
regulatory changes as well. She is presently working on policies, order sets, documentation and
education for: Wound VACs, new wound care products, DKA and insulin drip, enteral feeding, and
dysphagia.

4. I heard from all of my interviewees that Arlene Walch was an invaluable resource to the managers,
staff, graduate nurses, and hospital-at-large. One recurrent theme, however, was that they wished she
had more time to be involved and be a greater presence in the hospital. There is another nurse educator
named Regina Trental who is predominately responsible for unit-specific education. However, in the
realm of training graduate nurses, all of the interviewees expressed the fact that they felt that Arlene
was wonderful, but had too many responsibilities with not enough resources. I have to agree that this
seemed to be the case, as Arlene was being pulled in a multitude of directions during the relatively
short time I was with her. It was the overwhelming hope of everyone that I spoke to that Arlene will
eventually be able to have the funding to expand her department, but that the present financial climate
does not make this seem promising.