VOL: 103, ISSUE: 25, PAGE NO: 32-33
Penny Tremayne, MSc, PGDE, BSc, DipN, RGN
Senior lecturer in adult nursing, De Montfort University.
Abstract Tremayne, P. (2007) Improving clinical placements through evaluation and feedback to staff. nursingtimes.net
Clinical placements make up 50% of nursing students’ education, yet the evaluation of these experiences is variable, and clinical staff can remain uncertain about the effectiveness of promoting an environment conducive to learning. By implementing an evaluation tool, feedback can be given directly to the ward, good practice acknowledged and areas for development identified. This article describes the introduction of an evaluation tool and the consequences of its implementation.
Clinical placements are an essential aspect of nurse education. However, despite 50% of nursing students’ time being spent in clinical environments (NMC, 2004) the feedback offered to these areas can vary. This may be because evaluation of placements is undertaken within higher education institutions and feedback is not being appropriately disseminated, or because it lacks any relation to a specific placement (for example a group of students in a directorate) and so becomes generalised.
The provision of clinical practice placements remains a high priority in the educational quality agenda and. while annual placement profiles (educational audit) are an annual statutory requirement, not all practice staff are involved. Feedback often comes in the form of ‘thank you’ letters and chocolates from students who have enjoyed a particular placement, while sometimes none is offered at all. This leaves clinical staff unsure of how effective a placement they provided and can arguably contribute towards poor staff morale.
This was highlighted in the annual educational audit/profile of a placement ward and was a frustration to the university link lecturer for the clinical practice placement at De Montford University. It was decided that an individualised end-of-placement evaluation would be useful to:
- Acknowledge and strengthen existing good practice;
- Identify and troubleshoot aspects that could be improved;
- Motivate and develop staff;
- Enhance the relationship between the university link lecturer and clinical practice staff;
- Facilitate an improved learning environment and therefore ultimately improve students’ experience of the placement.
The evaluation tool
Few evaluation tools have been developed to elicit student nurses’ perceptions of the clinical learning environment (Midgley, 2006). The ward staff and university link lecturer that the evaluation would be undertaken in the final week of students’ placement after summative assessment of clinical practice objectives as we felt this would minimise potential positive bias. The evaluation was facilitated by the link lecturer with a member of the ward team present to listen and address issues directly. This was particularly symbolic to the students, as it demonstrated a partnership between education and practice (Brown et al, 2005) and meant their perceptions of the clinical learning environment were finally being represented.
A relatively simple evaluation was formulated to ensure immediacy and make the feedback real. This comprised a questionnaire asking students:
- What made this placement a good clinical learning environment?
- What do you feel could improve this placement as a clinical learning environment?
- Between a score of 1 and 10, 1 being very poor and 10 being excellent, what score would you give the placement overall?
Students were then invited to offer comments.
Once the students had completed these individually, the link lecturer facilitated a discussion around them, noting key issues on a flip chart, after which a nominal evaluation followed, enabling priorities to be identified more easily. Students were given five votes to indicate how strongly they felt about particular issues. To prevent any inhibitions they could ask the link lecturer and member of staff to leave the room while they voted.
The link lecturer summarised the issues identified and the member of ward staff indicated possible courses of action. Feedback from every evaluation was always presented at every ward meeting.
Students wrote their feedback on the evaluation form. The comments most frequently made to date are highlighted in Box 1.
Box1. Evaluation of the clinical placement
‘Excellent mentors with a good mix of recently qualified staff and more experienced staff.’
‘A good range of procedures [were] carried out so [there were] many learning opportunities.’
‘[I was] always made aware of anything that may be of interest to me.’
‘Good team work.’
‘Students are involved in all aspects of care.’
‘[I was] offered a lot of support and a chance to develop clinical skills.’
‘Staff gave me freedom to learn, and questioned me, which made me think.’
‘Students are truly seen as being supernumerary, which is nice.’
‘Introduction to the ward was very brief.’
‘To be more aware of what we as students want.’
‘Would have liked student pack earlier.’
‘Some assumptions [are made] that students are familiar with the geography of everything.’
It was up to individual students whether they wished an issue to be addressed or not by choosing to articulate it or not. However, the link lecturer collated feedback and provided staff with a summary report that included student comments. This method ensured that students did not feel compromised, in that feedback they did not wish to share with others was not addressed in public. This meant their perspective was acknowledged but not in such a public forum - some issues may be too personal for individual students to share, especially in a peer-group situation.
The following issues were discussed with students, practice staff and link lecturer after the initial evaluation, including the qualitative comments. These include the areas that students and staff feel are most significant.
One area that students felt could be improved was in relation to HCAs, whose knowledge and understanding of what it means to be a nursing student varied. For example, they reported that HCAs often asked them to undertake tasks despite the fact that the students were being supervised by a qualified member of staff who was allocating their work. This is widely acknowledged and can be attributed to the increasing reliance on HCAs to deliver bedside care and develop more technical skills(McKenna and Hasson, 2004).
Students stated that while they could learn a great deal from HCAs and that working with them was vital to enable the students to make the transition to clinical practice effectively (Holland, 1999), HCAs did not understand students’ needs and this could lead to a lack of cooperation and even hostility (Spouse, 2001).
In order to address these issues the link lecturer delivered an educational session to the HCAs, providing an overview of nursing student training and what it means to be a nursing student. Wright (2006) discussed the benefits of a study day for HCAs, highlighting that it helped them to appreciate their role and the role and expectations of nursing students, and increased awareness of learning opportunities available for students within their clinical area and the importance of encouraging student participation in these.
Role models and learning
Students found teaching in the clinical practice setting was a particular strength. Qualified members of staff recognised learning opportunities and encouraged students to be exposed to, or participate in, these. Repeatedly students said qualified staff were good role models and that this facilitated teaching and learning in practice (Murray and Main, 2005), as well as developing their competence and confidence (Donaldson and Carter, 2005). In particular, students identified the positive influence of the ward sister: ‘She was out there, setting the example, getting her hands dirty, she is a good role model to have.’ A figurehead such as this can not only establish and maintain an environment conducive to learning (Midgley, 2006) but also facilitate confidence (Chesser-Smyth, 2005).
Students also highlighted the opportunities to observe and participate in clinical skills. This can be attributed to the culture of the workplace - Wheeler (2001) considered that adults learn best in a culture that is characterised by physical comfort, mutual trust, respect, helpfulness, freedom of expression and an acceptance of people’s differences. Students reported that staff had the confidence to give them freedom to practise such clinical skills and that this was pivotal in their practice development. While clinical skills teaching can be simulated within a replicated skills-teaching environment, nothing can ever replace the ‘hands-on’ approach.
Students reported a varied orientation to the ward - some were shown around while others were not. Not being shown around not only compromised potential health and safety but also did not make the student feel particularly welcomed and compounded their fear in an acute environment. After receiving this information, staff implemented an induction programme.
Although only a one-day programme, the induction aimed to introduce students to the clinical practice area so they would be prepared for their allocation. It included a tour of the area, an overview of appropriate policies, introduction to key staff, identification of their mentor and agreement of their off-duty, and discussion of the learning opportunities available. Student evaluation suggested the day was successful. They reported finding it helpful and supportive, and that it allayed fears and made them feel a member of the team quickly.
Receiving positive feedback from students boosted staff morale and provided the impetus for enhancing and improving the learning environment for students. This contributed towards staff developing their teaching skills and thinking creatively about addressing areas requiring development. Rather than change being imposed upon them, it was they who identified the need for change and very naturally they followed the key concepts of change theory (Lewin, 1951; Box 3).
Staff working in clinical practice can take their own skills for granted. Working in a proficient or expert manner, the roles they undertake become second nature to them and they perceive them as ‘nothing special’. For nursing students, on the other hand, to observe and participate in such a role means so much to their personal, professional and academic development (Benner, 1984). Recognising this places a value on staff members’ knowledge and skills and almost verifies and makes that value tangible to them.
Box3. The change process (Lewin, 1951)
Unfreezing - identify issue(s) by undertaking evaluation, for example, the need to have an induction programme
Movement - action plan, implement and evaluate the change, for example, introduction of an induction programme
Refreezing - stabilise change, incorporate it as the ‘norm’, for example, all students participate in an induction programme
An average mean score was calculated and given to the ward staff. Although this was a rather snapshot approach, it did provide immediate feedback. The most common scores were between 7 and 10 and, typically, measured the attributes of the ward as a learning environment.
A priorities approach
Through discussion other points may be raised and, while those identified by students were all valuable, the link lecturer was mindful of the resources available such as time and staff. Nominal evaluation means a priorities approach can be adopted so staff are made aware of issues that need to be addressed most urgently.
The evaluation tool provided ward staff with the feedback they felt they were lacking and therefore addressed a deficit in the evaluation process. It has boosted morale on the ward, which was much needed in the current climate of uncertainty and change.
The results of the evaluation were the impetus towards instigating and developing new initiatives for staff who, because they were immersed in a situation, found it more difficult to take a step back and be objective. Relationships between the clinical staff and the university link lecturer improved, with the link lecturer being more visible and contributing towards a real and practical difference. It is a good example of partnership working using a proactive approach. Educationalists can appear remote to clinical staff, floating in and out of placements to visit students, not always communicating with clinical staff and so a reticence towards their role can form. This has bridged that potential gap.
Despite its success, not all clinical practice placements will require the implementation of such an evaluation method - link lecturer should respond to individual situations and need. It is, however, useful in the identification of needs.
Subsequent evaluations have been extremely positive so we may not need to undertake as many in the future; rather these could be conducted on a more ‘ad hoc’ basis for the purposes of review.
The evaluation process served its purpose as it was the catalyst towards an environment that is conducive, committed and ever working to enhance student learning. In light of this evaluation we would make the following recommendations:
- To share this as an example to other clinical practice areas as necessary to identify areas of development;
- To adopt a more valid methodology, such as a clinical-learning environment tool that can determine learners’ perceptions of their present clinical placement as a learning area.
Benner, P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. San Francisco, CA: Addison-Wesley.
Brown, L. et al (2005) The role of the lecturer in practice placements: what do students think? Nurse Education in Practice; 5: 84-90.
Chesser-Smyth, P.A. (2005) The lived experience of general student nurses on their first clinical placement: a phenomenological study. Nurse Education in Practice; 5: 320-327.
Donaldson, J.H., Carter, D. (2005) The value of role-modelling: perceptions of undergraduate and diploma nursing (adult) students. Nurse Education in Practice; 5: 353-359.
Holland, K. (1999) A journey to becoming: the student nurse in transition. Journal of Advanced Nursing; 29: 1, 229-236.
Lewin, K. (1951) Field theory in social sciences. New York, NY: Harper and Row.
McKenna, H.P., Hasson, F. (2004) Patient safety and quality of care: the role of the health care assistant. Journal of Nursing Management; 12: 452-459.
Midgley, K. (2006) Pre-registration student nurses’ perception of the hospital-learning environment during clinical placements. Nurse Education Today; 26: 4, 338-345.
Murray, C.,Main, A. (2005) Role modelling as a teaching method for student mentors. Nursing Times; 101: 26, 30-33.
NMC (2004) Standards of Proficiency for Pre-registration Nursing Education. London: NMC.
Spouse, J. (2001) Workplace learning: pre-registration students’ perspectives. Nurse Education in Practice; 1: 149-156.
Wheeler, J. (2001) Teaching students in the clinical setting. Nursing Times; 97: 40, 40-41.
Wright, K. (2006) The role of health-care assistants in supporting student nurses. Nursing and Residential Care; 8: 1, 35-36.