In the UK, the standards for undergraduate nursing education as well as practice are established and enforced through the Nursing and Midwifery Council (NMC) (2018), which expects registered nurses and nursing students to effectively apply theory to practice through its requirement that clinical practice should be evidence based. Therefore, the ability to apply theory to practice is a fundamental pre-registration requirement for all nursing students.
However, Greenway et al (2019) and McCaugherty (1991) observed that there is a disparity between theory and practice, highlighting that the complexity of clinical environments can never be described on paper in their entirety. There are many causes for the gap. For example, Shoghi et al (2019) found that the high student:educator ratio in undergraduate education created barriers to implementing innovative pedagogy around the application of theory to practice. Furthermore, they identified that both students and educators found research confusing and difficult to implement. Numerous commentators have asserted that it is the role of the nurse educator to minimise the theory-practice gap (Rolfe, 1998; Saifan et al, 2015; Akram et al, 2018) and to motivate and empower students to apply theory to practice (Falk et al, 2016).
According to Zhang et al (2022), theoretical learning normally occurs in the classroom, while clinical placements are where students apply this to practice. Modern pedagogy is moving towards active and interactive methodologies with the aim of improving the application of knowledge to practice. For example, problem-based learning promotes the acquisition of higher cognitive skills (Ellaway and Masters, 2008; Roblyer and Doering, 2013); blended learning, alongside interactive videos, discussions, debates and other interactive pedagogy, enhances engagement and promotes critical thinking (Dong and Goh, 2015). Such active and interactive pedagogy can lead learners to become fascinated by a subject and a consequential pursuit of knowledge (Ellaway and Masters, 2008; Prober and Khan, 2013).
In relation to clinical practice, Miller (1990) described the development of clinical competence from knowledge to capability in clinical practice through his pyramid of learning (Figure 1). According to Miller (1990) learning starts with knowledge of a subject, moving to ‘knowing how’ to do it (competence). Following this, ‘shows how’ indicated being able to perform the subject, finishing with ‘does’ being able to perform the skill using the knowledge base in practice. Classroom learning provides students with the opportunity to ‘know’ a subject, but it may not show them how to use the information.
Building on Miller's (1990) work, Ericsson (2004) acknowledged that practice was a vital component of developing into an expert practitioner, but practice alone did not guarantee development. When considering what made a person an expert, Ericsson (2004) suggested that the mindful and deliberate practising of skills, as opposed to automatic or unconscious actions, promoted development. As a result, Ericsson (2004) argued that one should seek new learning with the aim of continuously developing through mindful action, self-reflection and feedback.
Regarding the learning environment, Ericsson (2004) described authentic clinical situations (or scenarios) as more memorable and transferable into the real world than classroom learning. This resonates with Sweller's (1988) suggestions regarding the use of schemas to transport learning and experiences into long-term memory. Schemas concern the categorising of knowledge from which new learning can be attached to improve memory (Sweller, 1988). In this context, Sweller (1988) suggested using real-life examples or experiences in learning because these would link more easily to a schema.
Furthermore, practical learning uses knowledge in the undertaking of skills and allows for immediate feedback. For example, problem-based learning, such as that through simulation, can be stopped, explored, rewound and debated, thereby enhancing retention through gaining an understanding of underlying concepts (Ericsson, 2004).
Problem
In April 2020, the COVID-19 pandemic caused a reduction in clinical placement capacity. This affected student learning opportunities, including reducing opportunities to apply theory to practice in clinical settings (Swift et al, 2020). During this period, the number of applications for pre-registration nursing courses tripled in England, raising hopes that this would address the deficit in nursing staff (Department of Health and Social Care, 2021). This increase created further demand for clinical placements, and a need for innovative solutions to address this complex, fast-moving situation. Face-to-face teaching as well as clinical practice learning were rapidly replaced with online alternatives by nurse educators (Haslam, 2021). As Haslam (2021) observed, this provided an opportunity for old and new teaching methodologies to be combined into an improved, sustainable, hybrid pedagogy in undergraduate nurse education.
This article discusses the use of a virtual placement to improve student ability to apply theoretical knowledge to clinical scenarios, through hybrid, interactive pedagogy. The institution in which the virtual placement was conducted is a wider participation university, which attract diverse populations. Much of this student population may have been out of university for many years or have additional learning needs (Connell-Smith and Hubble, 2018). These individuals often consider themselves to be practical learners who prefer active or interactive learning pedagogy (McKendry et al, 2014).
Although various commentators have been promoting the inclusion of wider participating populations in the nursing profession (McKendry et al, 2014), it may be challenging to teach those who perceive themselves as practical learners to apply theory to practice through virtual means.
The additional focus of this article is on innovative, virtual, hybrid teaching and learning solutions, an approach that is suitable for educators working with wider participant populations.
Approach
Based on Miller's (1990) pyramid of learning (Figure 1), a virtual placement was created using evidence-based learning theories and multimedia technologies intended to replicate real-life experiences and promote problem-based learning.
Scenarios and case studies were collated from clinical experiences and mapped against student proficiencies, which are outlined in Box 1. Following this, the scenarios were filmed and adapted into interactive videos. Alongside each scenario, patient-specific documentation was created to complement the clinical narratives. This paperwork included patient admission documentation based on the Roper-Logan-Tierney activities of daily living (Roper et al, 2000) because this is the model taught in the adult nursing programme. Risk-assessment documentation was also created, as well as discharge planning forms and daily clinical notes. Observation charts for students to print out and complete were made available. Finally, a daily reflections and goal-setting sheet was created, and students were required to complete this at the end of each teaching day.
Box 1.Student proficiencies
| P1 | Provides people, their families and carers with accurate information about treatment and care, using repetition and positive reinforcement; accesses translator services, as required |
| P2 | Works in partnership with people, families and carers to monitor and evaluate effectiveness of agreed evidence-based care plans and readjusts goals as appropriate, utilising appropriate negotiation strategies, drawing on the person's strengths and assets |
| P3 | Maintains accurate, clear and legible documentation of all aspects of care delivery, using digital technologies where required |
| P4 | Makes informed judgements and initiates appropriate evidence-based interventions to manage a range of commonly encountered presentations |
| P5 | Effectively uses evidence-based nutritional assessment tools to determine the need for intervention |
| P6 | Assesses level of urinary and bowel continence to determine the need for support, intervention and the person's potential for self-management |
| P7 | Undertakes, responds to and interprets neurological observations and assessments and can recognise and manage seizures (where appropriate) |
| P8 | Uses contemporary risk assessment tools to determine need for support and intervention with mobilising, and the person's potential for self-management |
| P9 | Effectively manages the risk of falls using best practice approaches |
| P10 | Undertakes comprehensive respiratory assessment including chest auscultation eg peak flow and pulse oximetry (where appropriate) and manages administration of oxygen using a range of routes |
| P11 | Effectively uses standard precaution protocols and isolation procedures when required, and provides appropriate rationale |
| P12 | Provides information and explanation to people, families and carers; responds appropriately to questions about treatment and care |
| P13 | Undertakes assessments using appropriate diagnostic equipment, in particular blood glucose monitors, and can interpret findings |
| P14 | Undertakes an effective cardiac assessment; demonstrates the ability to undertake an ECG and interpret findings |
| P15 | Interprets normal and abnormal blood profiles |
| P16 | Manages and monitors blood component transfusions in line with local policy and evidence-based practice |
| P17 | Can identify signs and symptoms of deterioration and sepsis, and initiate appropriate interventions as required |
| P18 | Applies an understanding of the differences between risk management, positive risk taking and risk aversion to avoid compromising quality of care and health outcomes |
| P19 | Demonstrates awareness of strategies that develop resilience in themselves and others, and applies these in practice, eg solution-focused therapies or talking therapies |
| P20 | Participates in planning to ensure safe discharge and transition across services, caseloads and settings, demonstrating the application of best practice |
| P21 | Negotiates and advocates on behalf of people in their care and makes reasonable adjustments to the assessment, planning and delivery of care |
| P22 | Demonstrates effective person and team management approaches in dealing with concerns and anxieties using appropriate de-escalation strategies when dealing with conflict |
| P23 | Recognises signs of deterioration (mental distress/emotional vulnerability/physical symptoms), and takes prompt and appropriate action to prevent or reduce risk of harm to the person and others using, for example, positive behavioural support or distraction and diversion strategies |
| P24 | Manages the care of people receiving fluid and nutrition via infusion pumps and devices, including the administration of medicines where required |
Each week consisted of four virtual placement days, with one day of standard teaching (non-placement-related) at the university. The placements ran from 7 June to 2 July 2021 and involved 25 second-year student nurses, who used Microsoft Teams as the primary communication platform. Although students had not undertaken a virtual placement before, they had become accustomed to online learning delivery since the start of the COVID-19 pandemic.
A timeline with an overview of the placement, alongside activities and topics covered each week is shown in Figure 2.
Week one
At the start of week 1, students were introduced to the virtual resources and ground rules were established. During the first 2 days, students were involved in activities that equipped them with the knowledge and skills necessary to engage with the immersive virtual experience. These included demonstrations on using virtual resources and tuition on prioritisation, history taking, conflict resolution and managing difficult conversations (Figure 2; Table 1). On day 3, students were required to manage the virtual ward presented in Table 2.
Table 1. Virtual placement timetable: week 1
| Timeline | Activities | Resources |
|---|---|---|
Week 1. Days 1 and 2 Goal:
|
Morning and afternoon sessions
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| Week 1. Day 3 Goal:Immersive simulation, applying the learning from days 1 and 2 above | Morning activities
|
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Afternoon activities
|
|
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Week 1. Day 4 Goal:
|
Morning and afternoon activities
|
|
Table 2. Overview of the patients on the virtual ward: weeks 1 and 2
| Week 1, day 3: an overview of the patients on the virtual ward | ||||
|---|---|---|---|---|
| Patient | Presenting complaint | Role and activity during the virtual placement | How session was conducted | Main learning objective and link to proficiency (P) |
| 1 | Abdominal pain | Patient 1 needed to be admitted | Each group admitted a simulated patient* during an allocated time slot(*Volunteers played the role of simulated patients) | History taking and doing admissionsP 1,2,3,4,6,8 |
| 2 | Elective anterior cruciate ligament reconstruction | Patient 2 was frustrated because he could not find his iPad after coming out of surgeryHe should not be weight bearing | Each group was sent regular messages through their Teams chat showing frustration and unsafe actions. The messages were sent by the facilitator who was acting as the patient | De-escalation and managing complaintsP 18,19,22,23 |
| 3 | Ovarian cancer | Patient 3 was scared because she found out she was to have conservative treatment only and had been referred to the palliative care team | Students listened to an audio recording of the patient discussing her prognosis through headphones. Students were then required to make decisions about the prioritisation of the patient's care needs | Understanding the term ‘palliative’, pain management and managing difficult emotionsP 1,2,19,22 |
| 4 | Fall. Cause not known | Patient 4 was confused and had a full history, including urinary tract infections | Student watched a video in which the patient fell. Policies and risk assessments were available for the students to complete and discuss actions | Falls management and associated risk assessmentsP 1,2,3,4,6,8,921 |
| Week 2, day 3: an overview of the patients on the virtual ward | ||||
| Patient | Presenting complaint | Role and activity during the virtual placement | How session was conducted | Main learning objective and link to proficiency (P) |
| 1 | Exacerbation of chronic obstructive pulmonary disease (COPD) | Patient 1 was ‘sleeping well’ with 3 l of oxygen | An interactive video with branching scenarios was used to help students explore the effects of oxygen on patients with COPD | Oxygen useP 1,3,4,10,15,17,23 |
| 2 | Alcohol withdrawal | Patient 2 was waking up with excessive tremors and demanding a higher dose of chlordiazepoxide | Drug charts had been incorrectly completed regarding the patient's chlordiazepoxide. The students could bleep/call any member of the multidisciplinary team through Teams for support and amendment of the drug chart | Multidisciplinary team working, alcohol withdrawal and medicines managementP 1,2,3,17,18,19,22,23 |
| 3 | Lung cancer | Patient 3 was angry and confused about his new diagnosis. He felt angry towards patient 2 as he believed his condition was self-inflicted | Students listened to an audio recording of the patient discussing his anger and upset through headphones. His anger related to a perceived injustice of their diagnosis in relation to other patients on the wardStudents were then required to make decisions about the prioritisation of the patient's care needs | Palliative care and recognising stigmaP 1,2,19,22 |
| 4 | Motor neurone disease | Patient 4 was able to blink once for yes and twice for no. Patient was anxious and wanted her mum | A time slot was allocated for each group to find out what the patient wanted. Communication guidance was available in the patient's notes and in her ‘this is me’ documentation | Complex communication skills and importance of reading notesP 1,3,19,21,22,23 |
To mirror the unpredictable nature of a clinical setting, day 4 included a scenario that had not been discussed with students beforehand. Schön (1987) highlighted the need to introduce surprise into teaching so learners can experience discomfort and thoughts related to the unknown. Through this experience, students can begin to reflect on and analyse events in a way that promotes problem-solving skills and situation-based adaptation, as is experienced in clinical practice. This scenario and associated debate on day 4 asked students to consider differing views regarding pain management in people who inject drugs (Table 1).
Week 2
During the first 2 days of week 2, students received tuition to prepare them for the week's virtual experience. The topics taught included communication tools, medicines management and reading blood results (including arterial blood gases). On day 3, students were required to manage the virtual ward presented in Table 2.
On day 4, students explored a domestic abuse scenario. A vulnerable woman attending the virtual ward was accompanied by a domineering husband. Students were not informed that this was an abuse scenario and were asked to consider the admission. Once signs of an abusive relationship had been identified, students were required to manage the scenario. Because of the sensitive nature of this subject, the session was facilitated by a mental health practitioner with extensive experience in talking therapies.
Week 3
Week 3 was split into two parts: a scenario related to infection prevention and control; and the care of patients with common mental health conditions.
Day 1: students were asked to manage the virtual ward but were not made aware that the ward was on the verge of a norovirus outbreak. Table 3 outlines the series of videos used on the first day to depict the spread of norovirus within the ward.
Table 3. Videos on infection prevention and control over 4 admission days
| Video | Admission day | Main learning objective and link to proficiency (P) |
|---|---|---|
| Video 1Three patients and their paperwork are introducedAn additional patient (patient 0) is then admitted onto the ward | Day 1 | Admissions, discharges, risk assessments, stoma management and learning about conditions including Crohn's diseaseP 1,2,3,4,6,8 |
| Video 2The patients are starting to deteriorateOne patient with learning difficulties is becoming distressed | Day 2 | Risk assessments, de-escalation, documentation, talking to patients with learning difficulties (including using the ‘this is me’ document) and identifying deteriorationP 1,2,3,4,6,8,12,19,21,22,23 |
| Video 3Diarrhoea and vomiting is spreading through the ward. More patients are becoming distressed and generally unwell. Patient 0 feels better and is ready for discharge | Day 3 | Communicating with distressed patients from a variety of backgrounds, risk assessments, documentation and managing deteriorationP 1,2,3,4,6,8,12,19,21,22,23 |
| Image 4Photo of the healthcare assistant feeling unwell at homeThere is a sign on the door stating that the ward is closed because of norovirus | Day 4 | The meaning of the day is revealed to show the students had observed the spread of infection and were ready to do a root-cause analysisP 11 |
Day 2: students were asked to investigate the events of the previous day and complete a root-cause analysis to help identify how norovirus was spread. A specialist infection control nurse lecturer facilitated these first 2 days.
Day 3: students were presented with medical notes and a video of patients on a general ward with a combination of physical and mental health illnesses. Throughout the day, students were asked to manage the care of the various patients.
Day 4: forum theatre is a form of interactive drama that encourages audience interaction to explore ways of dealing with a problem or situation (D'Ardis, 2014), and, on day, 4 this approach was used to work through preconceptions, as well as how best to care for patients with various mental health conditions.
A mental health nurse lecturer facilitated these last 2 days.
Week 4
The fourth week of the virtual placement focused on the assessment and management of deteriorating patients (Table 4).
Table 4. Virtual placement timeline: week 4
| Timeline | Activities | Resources |
|---|---|---|
| Week 4 Days 1, 2, 3 and 4 Goal:Airway and breathing, circulation, gastrointestinal, shock and sepsis | Morning and afternoon sessions: day 1
|
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Morning and afternoon sessions: day 2
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Morning and afternoon sessions: day 3
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|
|
Morning and afternoon sessions of day 4
|
|
Case studies were used to consolidate learning from the previous weeks, as well as to develop skills in identifying and managing deterioration. The case studies were examined through discussion, which allowed students to problem solve different cases in small groups before exploring them as a whole group.
This week was facilitated by a lecturer with a background in critical care nursing.
Discussion
In the virtual placement described in this article, multimedia and subsequent information analysis and synthesis offered a multilayered learning experience, including back stories, patient notes, audio reflections and interactive videos. Students were immersed and engaged in an authentic learning environment, characterised by meaningful and in-context activities. Resources and activities provided a contextual platform, whereby learning could be directly related to clinical practice.
Problem-based learning lends itself to the principles of application of theory to practice by directly teaching how to use theory in clinical scenarios, and has additional benefits linked to collaboration and self-efficacy (Yew and Goh, 2016). In relation to Miller's pyramid, problem-based learning helps to fill the gap between ‘knows’ and ‘does’ (Bosse et al, 2010; King et al, 2018), as well as improve skills in critical thinking and problem-solving (Yew and Goh, 2016). Collaborative problem-solving activities required students to individually synthesise information from simulated resources before consolidating their learning in larger groups.
The resources used within the virtual placement, including interactive media, had a positive impact on learning, as reported during student evaluation and semistructured interviews with the learners. Multiple studies have found that interactive videos enhance students' curiosity and motivation, as well as promote self-efficacy (Brookes and Moseley, 2012; Kim et al, 2015; Whitton and Maclure, 2017); Hsin and Cigas (2013) found that interactive videos increase retention of learning. Moreover, audio files provide a powerful medium for teaching compassion and empathy (Adamson and Dewar, 2015; Waugh and Donaldson, 2016). Brame (2016) highlighted how the combined use of verbal/auditory and visual channels enhances memory and increases cognitive capacity, thereby promoting self-efficacy and learning.
According to Bandura and Adams (1997), an individual's self-efficacy is central to how they perceive present situations and subsequently respond to future situations. Self-efficacy may be defined as ‘belief in one's capabilities to organise and execute the courses of action required to manage prospective situations’ (Bandura and Adams, 1997:2). Indeed, self-efficacy is closely linked to goal-setting in relation to future decision-making (Lunenburg, 2011).
Locke and Latham (2006) denoted goals as identified improvements that one wants to make, thereby facilitating deliberate learning. In the process of working towards a goal, new discoveries are often encountered. In the virtual placement, students were required to regularly set goals to support personal and professional development and enhance self-efficacy. This links well with NMC (2018) standards, which expect students to set agreed outcomes while in clinical practice to maximise learning opportunities.
In relation to Miller's (1990) pyramid of learning (Figure 1), goals inspired the students to acquire relevant knowledge, consider how to implement it and start practising applying it in simulated scenarios. Within the virtual placement, an example of a goal included ‘improving knowledge and skills in managing de-escalation’. This goal required students to gain the knowledge through research or discussion (‘knows’), followed by considering how to implement it in clinical practice through discussion or forum theatre (‘knows how’). Following this, students demonstrated the learning in the virtual simulated environment (shows) before using the new skill in practice (‘does’). Although the final step can be actualised only in clinical practice, the virtual simulation created a feeling of uncertainty as would be experienced in clinical practice. This leads to self-discovery where previous unconscious incompetence develops into a known enigma to be explored (Yew and Goh, 2016).
Mcleod and Steinert (2015) also discussed four aspects of learning that influence students' ability to acquire and store new knowledge in a retrievable manner. These aspects were incorporated in the virtual placement. The first was in relation to the need to understand the meaning behind the concept being learnt. This was achieved through the systematic teaching of theory before, during and after the simulated sessions. The second aspect related to the ‘context of the learning’, where learning a clinical task is more memorable within a clinical setting (as opposed to from a textbook), and this was achieved through engaging with simulated sessions that were filmed in a clinical setting. The third and fourth aspects were met through regular reflections, group discussions, real-time feedback and the use of forum theatre that allowed students to experiment their responses (actions and behaviour) within a safe environment. These aspects relate to how deliberate learning requires a learner to be mindful during the performance of tasks and link the knowledge and related activity to a schema, thus enabling easier future retrieval and application of learnt responses when faced with similar situations.
The use of debates in teaching and learning has long been accepted as beneficial for developing analytical thinking, higher thinking processes and problem-solving skills (Spaska et al, 2021). Debates require the student to consider researched information in a variety of capacities, and be ready to answer any counter-arguments made (Spaska et al, 2021). Within the research process, the student will endeavour to find usable and compelling arguments, leading to a better understanding and an ability to transfer the information to other settings. Furthermore, debates are collaborative in nature, thus enabling learning from one another and developing skills in leadership and persuasion (Spaska et al, 2021). Therefore, debates encourage deep understanding of concepts, alongside deliberate learning and practising the art of memory. In relation to Miller's (1990) pyramid (Figure 1), debates create depth in learning the knowledge (‘knows’) and understanding how to use it (‘knows how’), thereby consolidating learning and promoting application of theory to practice.
Finally, reflection provides a useful learning tool for applying theory to practice by combining critical thinking, self-awareness and reflection (Schön, 1987; Finlay, 2008; Greenway et al, 2019). Unsurprisingly, reflective practice is a requirement for all nurses, as denoted through the revalidation process (NMC, 2019; 2021). However, people can gain from reflective practice only if they are psychologically ready for the experience and will progress only to where they are ready to get to (Finlay, 2008).
Within the virtual placement, each day ended with a group reflection activity, after which students were asked to individually reflect on the day. The reflection asked students to identify three points in each of the following: ‘what went well’, ‘what didn't go so well’ and ‘what will you take forward’. This reflective practice provided students with the opportunities to construct new and deeper understanding that could be used in future situations in a fluid and intuitive manner, as suggested by Schön (1987).
Lessons and limitations
One of the aims of developing the virtual placement was to allow students who could not attend clinical placements during the COVID-19 pandemic to complete placements in a virtual environment so they did not lose placement hours. Because of the urgency that drove the development of the virtual placement, an opportunity was missed when clinical placements restarted to conduct follow-up studies to measure the impact of the virtual simulated practice placements on clinical practice. At the time of writing this article, current virtual and face-to-face simulated practice placements, which have been informed by the lessons learnt from the virtual placement discussed here, are being run as part of a longitudinal study where impact on clinical practice will be measured.
In relation to teaching and support, the teaching team involved in the virtual placements found the virtual platform easy to navigate and use. This was mainly because they had become accustomed to online delivery of learning since the start of the pandemic. They were also able to use teaching and facilitation techniques that promoted student engagement, including the use of breakout rooms for small group tasks and interactive technologies such as Mentimeter (Rudolph, 2018) and Wonder.me, where every student was required to participate. The team also reported how students who were normally reserved appeared more vocal during the virtual simulated practice placement.
Despite these positive reports, poor internet connectivity impacted some students' experience of the virtual placement. This finding correlates with reports from the Office for Students (2020), identifying how the rapid shift to remote learning created issues around digital access, which students require to facilitate virtual learning. These issues were linked to inequalities in access to equipment and digital infrastructure.
Conclusion
The virtual placement is a viable pedagogy for enhancing the application of theory to practice, as well as addressing capacity concerns. This article presents a multidimensional virtual placement based on Miller's (1990) pyramid of learning and supported by various learning theories. It incorporated an array of multimedia technologies to replicate real-life experiences and promote problem-based learning.
The absence of real patients or deterioration created a safe environment within which students were able to explore theory and how it linked to practice. To further support the application of theory to practice, each scenario, lesson and case study was designed against specific learning objectives, linked to student proficiencies.
This innovative pedagogy looks to provide an alternative to the student nurse placement experience, while improving patient care by enhancing the application of theory to practice.
KEY POINTS
- Simulated placements provide the opportunity for students to demonstrate knowledge, skills and attitudes, prior to applying them in clinical practice
- Simulated placements reinforce the application of theory to practice by considering the theory before, during and/or after an immersive experience
- Simulated placements support retention of learning through repetition, as well as through learning in context
- Simulated placements can target learning according to student proficiencies
- Virtual placements can be created using an array of activities and multimedia
CPD reflective questions
- What activities and resources could you use to enhance your students' learning experience, as well as their ability to apply theory to practice? Consider virtual, hybrid and face-to-face approaches
- What could you implement in your teaching to support clinical placements regarding meeting Nursing and Midwifery Council competencies and proficiencies?
- How could you measure and monitor the application of theory to practice in your students?