The doorway assessment: Reducing anxiety and promoting critical thinking in nursing students

As a clinical instructor, I’m aware of my enormous responsibilities—to imbue nursing students with knowledge, teach them nursing skills, help them hone their critical thinking ability, and acculturate them to the profession by conveying what it means to be a nurse. These responsibilities are both challenging and rewarding.

As I meet each new clinical group, I often take the time to reflect on the clinical instructor’s unique role in each student’s educational experience. In the didactic classroom, students take exams and complete written assignments. In the nursing resource lab, they learn to master the psychomotor skills they’ll need. This gives them an opportunity to integrate their knowledge and skills as part of their clinical field experience.

Teaching a clinical course can be stressful for the instructor— the early wake-up call, having to leave the comfort zone of the nursing school, dealing with “difficult” unit staff. Students, many of whom already are apprehensive about providing care to their first patients, may sense the instructor’s stress and become even more anxious. This could result in a negative first clinical day, which could affect their entire clinical experience. In this article, I describe my technique for reducing students’ stress on this pivotal day in their nursing education.

One step at a time

Most clinical instructors who’ve been teaching for years become adept at assessing their students’ anxiety level during the preconference on the first clinical day. Some students appear confident and excited; others seem almost terrified. On this day, I focus more on the latter. After assigning the more confident students to a unit scavenger hunt, I take the fearful students one at a time to a patient’s room to conduct what I call a “doorway assessment.” I start by giving the student a brief cursory report on the patient in that room. Then I step into the room alone to meet the patient; I tell the patient we’ll be working with him or her shortly.

Then I step back into the hallway and ask the student to report everything he or she can observe about the patient. More often than not, students are amazed at how much information they can glean from this doorway vantage point. For example, the door to the patient’s room may have a sticker or magnet signifying the patient is a fall risk; a nutrition document, such as a calorie count in progress; or a coded reference to an infection control standard (such as contact or droplet precautions). I ask the student to comment on how these items might relate to the patient’s diagnosis. What did the student learn in the classroom and nursing skills lab about patient falls or infection control? As the patient answers, I provide reassurance and positive feedback. From the doorway, the anxious student has met the patient and begun an assessment.

Stepping into the room

Next, I enthusiastically ask the student to take a few steps with me into the room and report what he or she sees in the patient’s bathroom and around the bed. Items might include a specimen container, a 24-hour urine specimen collection in process, or an adaptive device, such as an elevated commode seat in the bathroom. I ask the student, “What can you conclude about the patient from these observations?”


After we step back into the hallway out of the patient’s earshot, I review with the student the process for obtaining specimens and discuss how adaptive equipment can help minimize the risk of patient falls. If the student reports seeing clutter or medications in the bathroom, we discuss the potential safety consequences and address how to communicate these findings to the appropriate staff.

Meeting the patient

I give more positive reinforcement, then tell the student it’s time to meet the patient. We enter into the room and, after introductions, I tell the patient about the student’s goals for the day—typically, taking vital signs, completing A .M. care, and performing a basic physical assessment.

I ask the student to observe everything he or she can about the patient. Usually, the student quickly discovers a wealth of information: oxygen delivery mode; urinary collection bag; hygiene status; indications of the patient’s ethical, cultural, or religious background (for instance, an accent or religious artifacts in the room); I.V. pole; visible wounds; and even clues to how long the patient has been in the hospital. (An admission folder visible on the bedside table may indicate a newly admitted patient.)

Again, we step back into the hallway (or the report room) and review the student’s findings. Why does the presence of a falls magnet on the door indicate the need for an adaptive device in the bathroom? What’s an appropriate nursing diagnosis for a patient at risk for falls, and where does this risk fit in with other nursing priorities for this patient? What evidence of falls precautions does the student see in the room? The student may report, for instance, seeing nonskid footwear, adequate lighting, lack of clutter, and a call bell within reach.

This conversation helps the student see the big picture, identify nursing care priorities, formulate a diagnosis, assess the environment, and speculate about the evidence-based interventions he or she learned in the classroom and lab that might be appropriate for this patient. It also underscores the importance of the nurse initiating the nurse-patient relationship by using therapeutic communication as well as clinical assessment skills. This conveys to students that the electronic health record isn’t the only window into the patient’s world.

When I leave that student and move on with my day, the student knows he or she must carefully review the patient’s health record, obtain vital signs, and complete the physical assessment—all the while keeping in mind our doorway assessment as a reference point. In the meantime, I may use the doorway assessment with other anxious students who need extra support in engaging their patients, or to challenge more confident, advanced students who’ve demonstrated greater mastery of clinical skills.

An energizing effect

This exercise energizes even the most reluctant students, who may excitedly check in with me throughout the rest of the clinical day to discuss how their “doorway” findings were confirmed (or, in some cases, disproved) by the physical assessment, health record review, and interdisciplinary collaboration.

Many of my colleagues reported their nursing school experience was marred by “terrifying” clinical instructors or teachers who seemed to thrive on unnerving their students. Clinical instructors have what can seem like an overwhelming responsibility: We must foster psychological resiliency in students to help them readily adapt to the demands of the nursing workplace. The doorway assessment is just one technique that can reduce students’ anxiety as they work through their first challenging clinical day and proceed with the complex process of using critical thinking and nursing skills to care effectively for patients in the clinical setting.

David Foley is a college lecturer at Cleveland State University School of Nursing in Cleveland, Ohio.

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One thought on “The doorway assessment: Reducing anxiety and promoting critical thinking in nursing students”

  1. Lydia Sapien says:

    love the article , I have been asked to be a preceptor and feel a bit nervous about it . A formal class is taught and , this candidate was more or less “given” to me.
    I have asked my employer to train me or re-assign the candidate
    (I asked very nicely)

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