Nursing is a practice-based profession. Therefore clinical education is an essential part of the undergraduate nursing curriculum. The quality of nurse education depends largely on the quality of the clinical experience (Elliot, 2002; Napthine, 1996). Students require effective clinical placements to allow the application of theory to practice (Elliot, 2002). These experiences are central to the student’s preparation for entering the workforce as a competent and independent practitioner (Penman and White, 2005; Papp et al, 2003).
VOL: 102, ISSUE: 14, PAGE NO: 35
Michelle Twentyman, Dip (nurs), BN, Grad Cert (critical care), MHealthSc (education), is acting nurse educator
Emma Eaton, BNM (nurs), is acting nurse educator,Amanda Henderson, RN, RM, Grad DipNurs (education), MSc, PhD, MRCNA, is nursing director, education; all at Princess Alexandra Hospital, Brisbane, Australia
The importance of clinical placement
Clinical placement provides the opportunity for students to observe role models, practice, develop their skills and problem-solving abilities, and reflect on what they see, hear and do (Landers, 2000; Thorell-Ekstrand and Bjorvellm, 1995). As they practise in the clinical environment, it is essential that the nursing student integrates theoretical content provided by the educational institutions with the realities of nursing practice (Cope et al, 2000; Dunn and Hansford, 1997).
There are a variety of influences in the clinical learning environment that can significantly limit and hinder the development of the learner (Clarke et al, 2003; Edmond, 2001; Pearcey and Elliot, 2004). Clinical education occurs in an environment that can be unstructured, unpredictable and overwhelming (Papp et al, 2003). This has the potential to generating feelings of vulnerability and anxiety in nursing students (Elliot, 2002). There are many facets that make up the clinical learning environment and it is the interactions of the nursing student with and within these elements that determine both the experience and the quality of their learning outcomes.
A major influence on the quality of a clinical placement is the professional nurses encountered by students both individually and as a team (Clarke et al, 2003).
Cahill (1996) went as far as to assert that the relationship between the staff and the nursing students is the single most crucial factor in creating a positive learning environment.
Students identify that the skills and attributes of nurse teachers, their attitude towards them (Dunn, 1997; Goopey et al, 2004; Jackson and Mannix, 2001) and access to relevant learning opportunities, is paramount in the achievement of positive learning outcomes (Pearcey and Elliot, 2004; Lofmark and Wilblad, 2001).
Recurrent themes in the literature that have been identified as supporting the learning of nursing students are the adoption by nursing staff of a professional role model and behaviour that present a positive attitude and accordingly influence the work culture.
A positive attitude
The professional orientation of nursing staff significantly influences student learning in the clinical environment. Poor treatment of nursing students is not uncommon in the workplace. This is often the result of:
- - Staff shortages;
- - Increased workload;
- - Lack of teaching skills;
- - Staff feeling threatened by nursing students (Davey, 2003).
If students do not feel supported in their environment - for example if they are treated with hostility and disrespect or even ignored completely (Davey, 2003) - they are unable to participate in the necessary communication to further their learning activities (Papp et al, 2003) and overall learning goals (Marson, 1982).
The amount of interest the nurse shows in the learning needs of the student and the key role she or he plays in their achievement are vital to the student’s development (Jackson and Mannix, 2001; Marson, 1982).
Chapman and Orb (2000) discuss the characteristics of ‘good’ clinical teachers as identified in their study The Nursing Students Lived Experience of Clinical Practice. They described these characteristics as:
- Having the student’s interests at heart.
These findings are consistent with other similar studies undertaken by Jackson and Mannix (2001), Nolan (1998), Dunn (1997) and Napthine (1996).
Registered nurses need to be aware of the consequences of any negative remarks they might make about nursing. Comments such as: ‘I don’t know why you would want to be a nurse’ make students question their entry into the nursing profession (Bender-Howard and Tasota, 2004).
Registered nurses can assist in the development of a supportive learning environment through their own attitudes to students, teaching, nursing and each other.
Positive ward culture
Nursing students report that their learning experiences during clinical placement are heavily influenced by the prevailing culture in the ward (Pearcey and Elliot, 2004). They feel vulnerable as they face unfamiliar patients, staff and routines (Cope et al, 2000).
A good ward atmosphere where staff viewed students as less experienced colleagues and treated them as such is described as being favourable to student learning.
If students are welcomed, appreciated and incorporated into the ward team then the clinical learning experience is considered positive (Papp et al, 2003).
Positive role models
The most common way in which students develop their own professional behaviours in relation to the delivery of care is through role modelling. The nursing student uses role modelling to create her or his own understanding of the patient’s world and the part that she or he has to play in it (Woodward, 2003).
Erikson et al (1983) define role modelling as ‘the facilitation and nurturance of the individual in attaining and maintaining and/or promoting health through purposeful interventions’.
The role of nurses who adopt teaching responsibilities is to facilitate this process for the student through the development of their professional behaviours and identity.
Valentine (1997) describes the outcomes of role modelling as being both positive and negative. Positive behaviours are those that are considered desirable for the professional development of the student.
Negative behaviours include unprofessional, unethical or inappropriate behaviours. As role modelling relies heavily on imitation and observation, both positive and negative behaviours can easily be adopted by the student.
Supporting student learning
At the Princess Alexandra Hospital in Brisbane, Australia, guidelines have been developed to facilitate these concepts of positive attitude, ward culture and role modelling into simple activities that can be readily adopted in practice.
These are presented to the nurses in the form of short ward in-service training sessions with the aid of colourful laminated posters to assist in reminding the staff of how they can personally make a difference to the student’s experience (Boxes 1-2). These basic guidelines have also been expanded to include specific clinical teaching strategies, the content of which is dependent on the study year the students are in.
Strong correlation is evident between how nursing students are treated by professionals, the learning opportunities available to them, the role models they encounter and their perceived satisfaction with the clinical experience.
Strategies to make students feel welcome and part of the team can include:
- Orienting the students to the ward, routine and the people they are likely to encounter during their placement;
- Ensuring students receive a handover sheet and are allocated tea breaks with other team members;
- Introducing students to the people involved in the care of their allocated patients, for example, pharmacists and physiotherapists, when discussing needs and changes to care;
- Encouraging students to be involved in every aspect of their patients’ care. This means adjusting their role as their scope of practice allows. For example, a student may not be allowed to perform the laying of a skin graft. However, they can be involved in setting up the trolley and environment, positioning and comforting the patient, reviewing the order and policy or opening sterile packets to assist in the process;
- Collaborating with students, telling them why you are doing things and involving them in the decision-making and problem-solving processes.
Strategies to ensure that nurses are a positive role model for nursing students include:
- Being conscious of body language, facial expressions and eye contact;
- Smiling, being friendly and introducing yourself to the student;
- Showing enthusiasm for the nursing profession and discussing nursing in a positive light;
- Providing the patient with quality care and encouraging the student to do the same;
- Ensuring any criticism is constructive and delivered in a way that does not humiliate or embarrass the student, providing a solution and rationale for the problem.
Strategies to help the student learn and work independently and take on responsibility include:
- Recognising the value of your own skills and knowledge and being prepared to share these with the student;
- Encouraging the student to ask questions. You may not know all the answers but demonstrating to the student how to find out the necessary information can be more useful than just telling her or him the answer;
- Making it clear what you expect of the student;
- Asking the student to identify her or his goals and aiming to secure learning opportunities that support the achievement;
- Being patient. It is important to remember that it can take three to five times longer for a student to complete a task than it would for an experienced, qualified professional.
- Allowing the nursing student to practise as independently as possible. Encouraging her or him to recognise the healthcare priorities for their allocated patient load, to develop their own time plan, deliver their care, handover and document their actions while offering appropriate prompting and constructive ideas for future improvement.
There is no dispute internationally as to the vital role the clinical practicum can play in the development of the skills, attributes and knowledge of nursing students.
As the registered nurse providing primary patient care is the most commonly encountered role model for the nursing student, it is vital that organisations establish effective methods that will fully prepare them to take on this responsibility in the future.
This article has been double-blind peer-reviewed.