Wednesday, November 22, 2006

offering best support through questioning

My recent musing has been around the subject of questioning for assessment.

Hand (2006) suggests that questions elicit evidence of competence that is not observable, by evoking a verbal response from the learner. It’s a valuable way of determining the level of knowledge a learner has, and identifying their understanding of events and interventions. Questioning rounds out the assessment picture, allowing for a more holistic and integrated review of learner competence.

Obviously questioning is important in the whole process of assessment, but I have had a wavering commitment to it. If you tracked on a chart my questioning history, the line would start high, indicating lots of questions being asked, before dropping down as the number of questions reduced, and right now the line is on the rise again as I recognise the need to incorporate questioning into a well rounded assessment plan.

Thinking back over my questioning history in this way is helpful. When I started this job I asked a lot of questions – I wanted to know what the graduates knew and what they thought about their practice. I wanted to identify knowledge deficits in order to help them develop a learning plan.

Understandably the graduates were uncomfortable with being questioned. They felt that since they had already qualified to be a registered nurse they no longer needed this level of scrutiny. I also began to feel uncomfortable – my position is one of clinical support and somehow giving the graduate the third degree in questioning didn’t seem appropriate support.

I stopped asking so many questions, but my evaluation of the graduates’ progress decreased. Thinking back to my last blog, I’ve come to realise that if my task is to monitor the quality and quantity of learning that has taken place in order to develop appropriate learning plans (which it is!), I simply cannot do that without asking questions. In order to offer the best clinical support, I must practice questioning.

Now I have come full circle, and I am gradually getting back into the groove of questioning, though I still find myself easily put off by the attitude of the graduates and the busyness of their day. I have to push through these obstructions and do what must be done not what feels good!

An incident the other day highlighted the issues here – the importance of questioning and the pressure not to question.

A graduate was working in a room with four patients, and one patient had two intercostal chest tubes (ICT). From experience, every graduate stumbles over the same issues with intercostal tubes every time, so I sidled up to this particular graduate and asked how they were going with the ICTs. They said they’d been looking after them for a few shifts now, and were OK with all that needed to be done. Since the graduate was obviously in the middle of a busy moment, I advised them that I would return soon and we could go through the ICT together.
Later I returned and pulled out the ICT observation chart and asked the graduate to explain what each observation meant. When we came to ‘air leak’ they started talking about checking the tubing for air leaks and noted that there had been a hissing coming from the suction connections the previous day. I then asked them if ‘air leak’ could refer to anything other than the tubing and when they didn’t know I took the opportunity to educate them correctly about ICTs and air leaks. This task was made more difficult because someone else had already ‘educated’ them about the ICT, so when I came along informing them that the original education was incorrect, they were somewhat dubious.

We continued to discuss ICTs, correct observation recording and other relevant protocols and the graduate continued on with their day. I walked away from the conversation suddenly very aware of the value of questioning. If I had merely looked at the completed observation chart, or taken the graduate’s word for it I might have missed the learning needs they had.

I’ve come away from this experience with a greater appreciation for the role of questioning in supporting the graduates. Now my task is to look at ways I can ease back into more thorough questioning - ‘How are you going today?’ and ‘Can I help you with anything?’ don’t really count!

I want to be the best Clinical Support Nurse I can, and questioning will help me better assess and provide support on the wards.

Tuesday, November 14, 2006

educator not policewoman

I’ve decided to observe the bluffing graduate (of previous post fame) a little more closely. That combined with asking experienced staff for feedback has been enlightening. It really is bluff and bravado being put on show – there are some significant deficits in the grad’s practice.

Yesterday I hung around them for a fair bit of the shift, assisting and generally keeping an eye on what was happening. A lot appeared to be happening, but somehow not much got done! At least some of the essentials didn’t get done.

How to approach the problem? How to raise it in a sensitive manner that was constructive and helpful? Last week those were my big questions. The first thing I had to do was work myself up to even speak with the graduate – they irritated me and I would quite happily have ignored their issues and left them to their own devices. (Yeah that’ll work!)

Yesterday I forced myself to pop by and happened to find the grad in a bit of a pickle. Every time they tried to attend to a task, a patient would deteriorate and need quick intervention, or some other interruption would occur. They were getting behind so I offered to help.

In that moment their whole attitude changed – they were appreciative of my assistance, and after dealing effectively with a bradypnoeaic patient, suddenly they seemed to have more respect for me.

As their attitude towards me changed, my attitude towards them also changed. I decided that the kindest thing to do was inform them that I had heard some less than favourable feedback, that my observations had confirmed this, and ask how they would like to approach the situation.

It worked! At the end of the shift we got together for a chat and the graduate opened up. They accepted the feedback, almost tearfully acknowledged their problems, and admitted to a large dose of stress. Somehow they’d become so focused on completing a tick list, that their patient care had suffered - they were so intent on achieving certain competencies that they let the basics slip.

What a relief – for me and them! They were able to share the burden that their sliding practice was placing on them, while their openness allowed me to offer support and suggestions for change.

It all reminded me of something I read in a book by Ci Ci Stuart (2003). She wrote that:
Monitoring progress is not about policing the learner. It is
very much about finding out the quality and quantity of learning which has taken
place and any difficulties the learner may be experiencing so that further
learning activities can be discussed and planned for further learning and

I’d been approaching this from the perspective of policing the graduate – “you aren’t doing this and you should be. Get your act together”.

When I decided to be honest and discuss how the graduate could best learn and develop, my attitude became more supportive and understanding and they were able to receive my feedback and discuss it honestly.

Our meeting ended on a good note. I ticked off some competencies for them, and we developed a plan for improvement.

And the bluff and bravado? One big cover up by someone who just needed to be understood and supported. Next time I’ll take the supportive approach from the start!

Friday, November 03, 2006

bluff or brilliance - assessment that is more than skin deep

I’ve been reading an article about assessment of clinical practice (Chambers 1998) and it’s left me feeling quite encouraged. It isn’t just me who has problems with how best to assess – no one really has a clue about the best way to provide reliable and valid assessment in the clinical setting! Admittedly this article is from 1998 and more thought has gone into the topic since then, but here is a literature review that cannot describe the best way to assess nursing practice.

One interesting point in the article is that many nurses feel that overconfidence of a student or beginning level practitioner suggests unsafe practice or incompetence.

I’ve been caught out by this one before. It was only towards the end of one graduate’s six month placement that I realised their practice was based on bluff and bravado. They seemed to know the answer to lots of questions, or at least their withering tone of voice suggested they knew everything (“do you really think it’s necessary to ask me these questions when I obviously know the answers?!”). However in the cold light of day, their practice wasn’t up to scratch. By the time I finally saw through the bluff and recognised their incompetence it was too late - they only had a week or two left on the ward.

Interestingly I have an overconfident graduate under my care at the moment. Again they are full of answers, but in this case they are also derisive in their attitude to more experienced staff on the ward. I’m continually hearing about the way other nurses don’t know the answer to any of the questions they ask. I suppose the good thing is that the graduate then sniffs out policies and procedures to find the answer for themselves – but it’s the attitude that bothers me. It’s almost as if they feel invincible – “I don’t trust anything anyone tells me because I must find the answers on my own”. No one in nursing is invincible – we all come a cropper with some silly mistake at some point, usually when we thought we were most invincible!

This particular graduate is only half way through their placement, so I have time to investigate and intervene. I’ve worked with them once, but because I struggle to stand back and be a detached observer I’ve not seen what they do when working completely independently. I think it’s time to pull out my best observer skills and seek out the truth of what’s going on here. Are they competent or are they employing a clever ruse?

Here I come to accurately assess exactly what this graduate is up to.

The article mentioned here is:
Chambers MA , 1998, "Some issues in the assessment of clinical practice: a review of the literature" in Journal of Clinical Nursing 7, 201-208