Strategies to Decrease Student Anxiety and Improve Patient Safety in a Critical Care Clinical Setting

Submitter Information

Author: Julie Hopkins, DNP, RN, PHNA-BC
Title: Instructor
Institution: Frances Payne Bolton School of Nursing, Case Western Reserve University

Competency Category(s)
Patient-Centered Care, Safety

Learner Level(s)
Pre-Licensure BSN

Learner Setting(s)
Clinical Setting

Strategy Type
General Strategy

Learning Objectives

Through participation in this clinical exercise the student will:
1. Discuss the impact of student anxiety on patient safety in a critical care clinical setting.
2. State the effect reflective journaling has on decreasing anxiety.
3. Review previously learned skills in a lab setting during critical care clinical orientation as a means of decreasing anxiety in practice.
4. Demonstrate the effect student anxiety has on communication with patients and the care team.
5. Analyze the relationship between student anxiety and the provision of patient-centered care.

Strategy Overview

The start of a critical care clinical rotation can be an exciting time for many nursing students. For some, however, the prospect of caring for critically ill patients in an intensive care unit (ICU) can be overwhelming. While some apprehension is to be expected, excessive anxiety can impede students’ ability to think clearly, therefore increasing the risk of errors and ultimately jeopardizing patient safety. Too much anxiety may also negatively impact students’ interactions with their patients, compromising communication and affecting the provision of patient-centered care. In an effort to decrease students’ anxiety and increase their comfort level in caring for critically ill patients, an orientation day “skills fair” along with reflective journaling will be introduced in this junior level BSN critical care course.
Prior to the start of the course, students will be asked to reflect on their preconceptions of critical care clinical and identify any fears or anxieties they may have regarding caring for critically ill patients. A brief questionnaire will be posted on the course Canvas site one week prior to the start of the clinical rotation. Questions will include “What are your perceptions of the critical care clinical rotation?” “Do you have any fears of caring for ICU patients? If so, discuss them.” The students will upload their responses to the Canvas site prior to the first day of clinical. The content of this reflection will not be graded. Students will simply earn credit for submitting the assignment on time.

On the first clinical day, each instructor will have their group engage in a roundtable discussion where students will be able to share their thoughts, feelings, and concerns regarding caring for critically ill patients. Students will not be mandated to share what they wrote in their pre-clinical assignment, but faculty will promote an environment where students feel safe to discuss their feelings. Students’ fears and apprehensions will be acknowledged. Instructors will stress to the group that the focus of this clinical rotation is not only hands-on patient care and clinical skill development, but also confidence building, patient safety, communication, and the provision of patient-centered care.

Following this discussion and a tour of the ICU, students will reconvene in the school’s nursing lab for a “skills fair.” The following clinical skills were chosen to review:

1) Administering medications via a gastric tube
2) Inserting an indwelling Foley catheter
3) Inserting an intravenous (IV) line, administering medications by IV bolus, and administering medications by IV piggyback
4) Suctioning a tracheostomy and providing care of a tracheostomy
5) Medication math calculations

These skills were chosen because of the high likelihood of having the opportunity to perform them in an ICU setting. Students enrolled in this course have tested out on these skills in their prior medical-surgical rotation. However, they likely had little opportunity to perform the skills in the clinical setting. The goal for the skills fair is to refresh students’ memory on correct technique and procedure, increase their confidence, and decrease their anxiety prior to the start of the ICU clinical rotation. Refining their skills, decreasing their anxiety, and improving their confidence will ultimately improve patient safety in the clinical setting.

During the skills session, students will break into small groups and move through the five stations at 20-minute intervals. A clinical instructor will be at each station and will demonstrate the skill for students, then allow each student time to practice. If additional time is needed on a skill, students may return to repeat it after cycling through each station. Instructors will provide feedback and assistance, but students will not be tested or graded on each skill. The goal is to provide a low-stress environment for students to gain confidence prior to working with critically ill patients.

Reflective Journaling
Students will also complete one structured reflective journal during the seven-week clinical rotation. Reflection will allow the students to explore their thoughts and feelings related to the clinical experience. It will also help students understand their stress and anxiety, and the impact these factors have on patient safety and the provision of patient-centered care. Open-ended questions include “Identify and describe aspects of your clinical day which may have caused you to feel anxious.” “Describe how you communicated your feelings of anxiety to your clinical instructor and/or assigned nurse. How did communication with members of the health care team impact your anxiety level?” “What aspects of patient safety were your focus today?” “Evaluate your performance of patient care today. Include what you learned and where you feel you could improve, particularly in regard to patient safety.” A deadline for submitting this reflective assignment to the course Canvas site will be given to students at the beginning of the course.

Finally, students will also complete a post-course reflection of this experience. The same questions posed at the beginning of the course will be revisited at this time. The questions will be posted on the course Canvas site and will include “Reflect on your fears and concerns prior to the start of the course. Based on your experiences during this rotation, what are your current perceptions of caring for critically ill patients?” “Reflect on your experiences from this clinical rotation. Did your anxiety level change throughout the rotation?” This post-course reflection is not graded, but credit is awarded for submitting it on time.

Submitted Materials


Additional Materials

See the attached files:
1. Reflective journal template
2. Critical reflection rubric

Evaluation Description

One of the most helpful aspects of journaling is having the opportunity to reflect on an experience and think about how to improve upon a similar situation in the future. Through journaling, students have a written memoir of an experience. They can reflect on this, and think about how they overcame this particular difficulty. In this way, it encourages refinement of action (Miller, 2017).

The students’ structured reflective journal will be scored based on content, quality of writing, and timeliness of submission. The true measure of success with the assignment, however, is a noted decrease in anxiety level for the student in caring for critically ill patients. For this reason, the focus of their journaling should not be on “hands on skills” performed, but on their own personal reflection of their feelings toward their patient assignment, and how those feelings impacted patient safety, communication with the patient and interprofessional team, and their provision of patient-centered care. Their ability to be able to make connections between their attitudes and fears and their overall performance will lead them to professional growth. The goal is for students to continue their practice of reflective journaling in future courses. Ideally, they may not only identify connections between student anxiety and patient safety, but also recognize their strengths and weaknesses which impact communication, safety, and the provision of patient-centered care.

Ganzer, C. A., & Zauderer, C. (2013). Structured learning and self-reflection: Strategies to decrease anxiety in the psychiatric mental health clinical nursing experience. Nursing Education Perspectives, 34(4), 244-247.
Miller, L. B. (2017). Review of journaling as a teaching and learning strategy. Teaching and Learning in Nursing, 12, 39-42.
Zhao, F.-F., Lei, X.-L., He, W., Gu, Y.-H., & Li, D.-W. (2015). The study of perceived stress, coping strategy and self-efficacy of Chinese undergraduate nursing students in clinical practice. International Journal of Nursing Practice, 21(4), 401–409.