Meeting the Clinical Challenge

Nursing is a profession of doing. A nurse’s education begins with learning critical concepts from books and lectures, but to be fully prepared to care for patients, nurses must learn by doing. 

Two approaches go hand-in-hand in providing students the experience they need to gain proficiency and competence—laboratory simulations and clinical placements guided by preceptors. Cizik School of Nursing at UTHealth’s Beth Ulrich, EdD, RN, literally wrote the books on both. The second edition of her “Mastering Precepting: A Nurse’s Handbook for Success” was published in 2019, and an update of her similarly titled “Mastering Simulation” book was published in 2020. 

“Experiential learning is very important,” Ulrich said. “You can’t read a book and be great at starting an IV. There are a lot of things in nursing that you have to see and do to learn.” 

State-of-the-art Sim Lab

Simulation labs, where students begin their hands-on education, traditionally focused on teaching basic skills and procedures, but they have advanced to mimic a multitude of more realistic experiences.

“Sim labs have been gaining a foothold in all of health provider education over the past 15 years or so,” said Eric Christensen, director of Cizik School of Nursing’s facility. “They can recreate experiences that you might have to wait hours and hours to see— or might never see—when working with real patients.” 

Cizik School of Nursing unveiled its newly expanded Simulation and Clinical Performance Laboratory (Sim Lab) in January 2020. The renovation added 9,000 square feet of space and increased the school’s capacity to accommodate nearly twice as many undergraduate and 70% more graduate students as before. Spaces can be modified to simulate experiences ranging from home health care to childbirth to emergency medicine. Faculty members or preceptors monitor students, direct scenarios, and manipulate high-tech robotic “patients” from a centralized audio/visual control room. 

“Plans for the expanded Sim Lab started several years ago with Dr. Cathy Rozmus, our vice dean for academic affairs, sketching a layout to maximize functionality, incorporate cutting-edge technology, and accommodate growing enrollment,” said Dean Diane Santa Maria, DrPH, RN. “Simulation is a very valuable part of our educational process, and I am grateful to our faculty and staff who have worked so hard to create this state-of-the-art learning environment for our students.” 

Because of the capability to recreate specific low-occurrence, high-risk scenarios, students earn twice as much credit for time in the Sim Lab as they do in real-world clinical rotations. Still, no matter how sophisticated the simulator, nothing can fully substitute for caring for human patients. 

“We’ve shown that we can replace about half of clinical experience with simulation,” Ulrich said. “The rest of it needs to be hands-on with a live patient in front of you.” 

Dedicated Preceptors

Educating nurses would be impossible without experienced professionals guiding students through the clinical environment to gain confidence and competence. 

“I think back to a lot of people in my life who helped me, mentored me, and I feel that it is my obligation to do the same,” said Annie Benjamin, a psychiatric-mental health nurse practitioner with UTHealth Harris County Psychiatric Center who serves as one of the nursing school’s clinical partners and is a graduate of the school. “When some of the students call or email and tell me that they passed the boards, that is an incentive for me.”

Experienced nurses follow different paths to precepting—some may be asked by their employers to work with students, or students may request their help. 

One highly sought-after preceptor and Cizik School of Nursing graduate is Amanda Bergeron, an acute care nurse practitioner who works in the heart failure intensive care unit at Memorial Hermann Heart & Vascular Institute at Memorial Hermann-Texas Medical Center. 

“I work in a very high-acuity unit that provides great experience for students,” Bergeron said. “Precepting a student can slow me down as far as my workload, but overall it’s worth it. It also challenges me to be at the top of my game, because if I don’t know the answer to a student’s question, I have to do the research to find it.” 

At some hospitals, precepting brings extra pay or can be a step on a career path. However, it can be a tough job, and precepting opportunities should be considered carefully, Ulrich said. The new edition of her book on precepting includes a list of questions for nurses to ask their managers to ensure they will have the resources and support needed to be successful as preceptors. 

Being a good preceptor requires patience, confidence, experience, and a desire to teach, but a long career isn’t necessary. In fact, some of the best preceptors can be those who are newer to the workforce and can better relate to colleagues who are just beginning their clinical work, Ulrich said. Nurses usually must have at least one year of experience to qualify to be preceptors. 

“Once you feel confident, then I think it’s very rewarding to be able to precept students,” said Bergeron, who adds that precepting helps keep her in touch with other nurse practitioners in the health care community. “It also helps with keeping the standards of the profession high.” 

The COVID-19 factor

The 2020 pandemic sent even the best-laid plans back to the drawing board. Halfway through the spring semester, the newly remodeled Sim Lab sat empty, and clinical sites halted rotations. Didactic courses remained online for the summer, but students were able to come to campus in staggered shifts to complete Sim Lab requirements. 

“Because of the social distancing requirements, we are limited in the number of students we can get through,” said Christensen. “We have extended hours to get more students through the process.” 

Necessity being the mother of invention, faculty came up with some innovative virtual simulations that followed the linear progression of patient care, noted Padmavathy Ramaswamy, PhD, RN, assistant professor in the Department of Graduate Studies. For example, as the number of COVID-19 cases rose in Houston over the summer, an annual interprofessional simulation shifted to a telehealth scenario, with students from Cizik School of Nursing and McGovern Medical School at UTHealth collaborating on a case study that accurately mimicked the way many real patients with nonacute conditions received care during the pandemic. 

“A lot of the students had already secured preceptors for the summer, then COVID hit,” said Ralph Leal, Cizik School of Nursing’s graduate clinical coordinator. With elective procedures canceled, a few of the preceptors were unable to serve students because they found themselves without work. 

The need for preceptors to guide students in the clinical environment and in the Sim Lab will be even greater as we emerge from the pandemic and more new nurses are needed to relieve those who have spent months on the front lines. The process for being approved as a preceptor can be fairly straightforward, especially if a clinical site is already under contract with the nursing school, said Leal, who verifies preceptor credentials on individuals who apply. 

“I don’t think there’s any job in nursing that doesn’t need a preceptor to help them through,” Ulrich said. “This is where the rubber meets the road and how we take care of the next generation of nurses.”