Staff Nurses and Students: The Good, The Bad, and The Ugly

Transcription

1 Angela M. Koontz Judy L. Mallory Jane A. Burns Shelia Chapman Staff Nurses and Students: The Good, The Bad, and The Ugly Elements identified by student nurses as impacting learning in the clinical learning environment were ex - plored. A significant element identified by participants was the staff nurse. Strategies for improvement and increasing learning opportunities are included in the discussion. Angela M. Koontz, MS(N), RN, is a Nursing Instructor, Caldwell Community College and Technical Institute, Hudson, NC. Judy L. Mallory, EdD, RN, CNE, is Associate Director, School of Nursing, Western Carolina University, Candler, NC. Jane A. Burns, PhD, RN, is Assistant Professor, Western Carolina University, Black Mountain, NC. Shelia Chapman, MSN, RN, is Assistant Professor of Nursing, Western Carolina University, Candler, NC. One of the most valuable components of a nursing program is the clinical learning environment (CLE). This setting provides students with unique learning opportunities in which classroom theory and skills are put to the test with real life situations. Clinical learning environments include hospitals, doctors offices, health departments, hospice units, and other health care settings utilized for student learning. The CLE differs from the classroom or lab setting in many ways. Typically, the classroom and labs are controlled by instructors. This includes lectures, labs, tests, dress codes, student conduct, break times, attitudes, and the learning environment atmosphere. The CLE is a different story. Massarweh (1999) described the clinical setting as a clinical classroom. However, the CLE is unpredictable and relatively out of the nursing instructor s control. Attitudes, work ethics, staff members, unit environment, equipment and supplies, census, and patients and family members are elements of the CLE that cannot be controlled by instructors. This unpredictable environment is very different from the classroom and can be a major shock for students. Also, the transition from student-learner to student learner-worker can be difficult and confusing for students and even the CLE staff. Staff members may view students as workers only, especially when patient care demands are high. Pearcey (2007) indicated nursing students are taught to provide holistic care but at times may be faced with more technical tasks than holistic patient care. In this research study, the various elements of the CLE s role in the development of student nurses perceptions of nursing were explored. The above-mentioned factors are but a few of the elements that influence learning within the CLE. The aim of this study was to explore student nurses perceptions of their CLE experiences with the hopes of discovering positive and negative factors influencing learning. Conceptual Framework Among student nurses, the CLE is perceived as the most influential context for gaining nursing skills and knowledge (Chan, 2001). Benner s (1982) theory outlined the process of a nurses development from a new graduate or novice to an expert nurse. Benner described the sequence in which nurses attain their skills and knowledge in the clinical environment. The different stages of Benner s (1982) theory are novice, advanced beginner, competent, proficient, or expert nurse. Three common themes further define nurses development. First, clinical knowledge does not rely on the principles of theory alone but is intertwined with patient interaction and responses to care. The student nurse may experience anxiety 240 MEDSURG Nursing July/August 2010 Vol. 19/No. 4

2 regarding the clinical rotation because of his or her novice level of skill and knowledge. The second theme describes the development of perceptual awareness, the ability to separate relevant information from the irrelevant within a clinical problem (O Connor, 2001). Percep - tual awareness stems from the nurse s intuition about the clinical problem. Individual nursing intuition develops with knowledge and experiences gained from previous clinical problems. O Connor (2001) stated,...intuition is not guessing or feeling; it is a deep knowing, and a necessary element of expert practice (p. 48). The third theme represents a quality of the expert nurse that cannot be taught in a classroom, but through the interaction of nurse-patient practice. An expert nurse not only knows what is important within a clinical problem, but also what needs to be done. This conveys confidence and assurance to patients and their families. Benner s (1982) novice-to-ex - pert theory explained how nurses intuition develops with knowledge and experiences from clinical practice. Nursing students begin their education as novices. O Connor (2001) indicated the novice stage describes the initial stage of development for nursing students. The novice s focus is on rule-based activities and the application of theoretical knowledge (p. 49). Upon graduation, nursing students are advanced beginners. Task completion rather than patient management is the goal of the advanced beginner (O Connor, 2001, p. 50). Competent nurses show greater awareness in distinguishing what is important from what is not important. Clinical experiences have contributed to the development of this awareness. Also, patient focus increases as organization and management of multiple patients becomes easier. Proficient nurses demonstrate expanded personal awareness and intuition above that of competent nurses. O Connor noted expert nurses are able to respond intuitively to a patient situation because they understand what is needed and why. O Connor suggested expert nurses have developed from a state of critical thinking to thinking like a nurse. Benner s theory differentiated the levels of nursing expertise and supported the clinical setting as an essential aspect of nursing education. Literature Review Databases utilized for this literature review included EBSCOhost, MEDLINE, and CINAHL. CLEs, student nurses, student nurses perceptions of CLEs, and student nurses perception of learning in the CLE were the main topics searched, with initial searches limited to the past 5 years. The results for more specific articles related to student nurses perceptions of learning in the CLE were limited. The timeframe was revised to include the past 15 years. Research topics of student nurses, CLEs, perceptions, and learning provided a broad range of articles related to nursing, nurse educators, and pharmacology and medical students. However, results for student nurses perceptions of the CLE and learning were small. Previous studies described other influences on student nurse perceptions of CLE experiences. A study completed by Dunn and Hansford (1997) explored the perceptions of the CLE held by 229 second- and third-year student nurses. Qualitative data obtained from student interviews revealed five major themes: staff-student relationships, nurse manager commitment, patient relationships, student satisfaction, and hierarchy and ritual. Researchers found interpersonal relationships be - tween the participants in the CLE were significant in the development of a positive learning environment. Also, within the CLE, a positive learning environment was the result of student satisfaction as well as an influential factor for creating a positive learning environment. Dunn and Hansford (1997) suggested good collaboration among nurse educators, clinical sites, and other participants providing clinical education of student nurses promotes the creation of a positive CLE and the development of well-educated, competent nurses. A more recent study conducted by Ranse and Grealish (2007) explored nursing students experience of learning in the clinical setting of a dedicated education unit using a communities of practice framework. Open forums should be held for clinicians to discuss their concerns regarding facilitating student learning and to collaboratively develop strategies to support student learning in practice (Ranse & Grealish, 2007, p. 176). Papp, Markkanen, and von Bonsdorff (2003) conducted a study related to student nurses perceptions regarding their clinical learning experiences. Data were collected through unstructured interviews with 16 student nurses. Participants were asked to describe the importance of the CLE along with good and bad learning experiences. Three major factors were revealed: the appreciation and support received by students, the quality of mentoring and patient care, and students selfdirectedness. Students felt clinical practice and available opportunities provided a reflection of the process of becoming a professional nurse. This study also supports the previous suggestion by Dunn and Hansford (1997) regarding the establishment of good collaboration between nurse educators and clinical learning environment staff to create a positive learning environment. Purpose This study was conducted to explore student nurses perceptions of their CLE experiences. Prior research related specifically to student nurses perceptions of learning in the CLE was limited. The aim of this project was to raise awareness of the significance of the CLE and identify positive and/or negative factors within a CLE which affect learning from the student nurse perspective. Methodology The design of this study was descriptive and exploratory with a qualitative approach. It used elements of grounded theory or the general inductive method which allows researchers to collect and categorize data, describe emerging central phenomenon, and then MEDSURG Nursing July/August 2010 Vol. 19/No

3 recycle earlier steps (Polit & Beck, 2008). Institutional review board approval for this study was provided by the participants university and the graduate school of Western Carolina University. Con - fidentiality statements were signed by the researcher and the transcriptionist regarding all data collection. Participants were made aware of the confidentiality statements and security measures, which included shredding of all notes, transcripts, and any copies pertaining to the study by the researcher 6 months after the study was completed. A formal presentation was made regarding the project to the potential target group participants, senior baccalaureate nursing students in their last semester of education at a single North Carolina university. A written information sheet detailing the purpose, implications, and potential harm or benefits of the project was given to prospective participants. Written consent for participation and permission to audiotape the meetings for transcription were obtained after participants had the opportunity to read the information sheet and have any questions answered. Participants were in - formed fully regarding the proposed research and its voluntary participation. During this presentation, the setting, dates, and times for meetings were discussed. In accordance with expressed de - sires of the majority of participants, focus group meetings were arranged in on-campus rooms be - fore and after participants scheduled classes. A total of 10 participants volunteered for the study, three males and seven females ages The researcher led three semi-structured focus group meetings with a set of trigger questions aimed at addressing the research questions. Group 1 consisted of two participants, Group 2 consisted of five participants, and Group 3 consisted of three participants. In an effort to provide anonymity, numbers were used in place of participants names. The meetings were audiotaped for greater accuracy of data collection. Verbal permission for recording was obtained at the beginning of each meeting. A digital recorder with memory card was used for recording. The memory card was given to a transcriptionist for written transcription of each meeting. An electronic file for each meeting was created along with three paper copies of each meeting transcript. Analysis of the Data Methods of qualitative analysis to determine the most effective approach were reviewed. Thomas s (2006) general inductive approach was utilized to sort and organize the collected data. The assumption of this approach...is to allow research findings to emerge from the frequent, dominant, or significant themes inherent in raw data, without the constraints imposed by structured methodologies (p. 238). Credibility Credibility is more consistent with qualitative research and refers to confidence in the truth of the data and interpretations of them (Polit & Beck, 2008, p. 539). Strategies used to enhance the quality of this research study included audiotaping of all interviews to capture rich details, peer examination of the data by a nurse educator with qualitative research experience, and data triangulation. According to Darlington and Scott (2002), the process of analysis identifies patterns emerging from the data and the relationship among those patterns. Investigator triangulation was utilized to reduce the possibility of biased decisions and idiosyncratic interpretations of the data (Polit & Beck, 2008, p. 547). A researcher and an assistant independently read the transcripts and began compiling a list of codes. The researchers compared their list of codes to create a master list in which the data were coded into categories and common themes. Findings The use of open-ended questions provided the opportunity for participants to respond in their own words (Polit & Beck, 2008). The questions gave structure to the discussions without hampering expression of beliefs or feelings. The responses provided rich, detailed descriptions, and examples of student nurses perceptions of learning in the CLE. Question 1: To what degree do clinical learning experiences impact student nurses perceptions of nursing? Common participant responses included holistic, caring, empowering health, and presence. As the interviews progressed, participants were asked to discuss what they knew about what nurses do. Participant 2 s response was typical of other participants: They re a direct care giver. They re an advocate, educator, case manager. Question 2: What elements of the CLE do student nurses identify as having a positive impact on learning? Preceptorship. The most common theme identified by participants as having a positive impact on learning in the CLE was the preceptorship. According to Parti - cipant 1, Being with a preceptor and feeling a part of the team, it was my best clinical experience. I got to do so many different things, getting familiar with the equipment, IVs and trach training, and just that kind of stuff that normally you don t get a lot of hands on. And also, in my preceptorship, I got a lot of experience. The most intimidating factor of nursing to me was calling doctors and giving reports. They helped encourage me to do that or just broke it in slowly. I thought that was good because we never get any of that in a traditional clinical. As the interview progressed, participants were asked what made the preceptorship so important. As Participant 1 noted, And when you have somebody who is really open, really glad to have a student, glad more people are going into nursing because they care about nursing and they want more people to do it, they re more open to questions. Ironically, Participant 4 identified non-receptive preceptor nurses as having a positive impact on learning. But I think certainly that s not ideal and working with nurses that aren t receptive to the student experience sucks, but it s 242 MEDSURG Nursing July/August 2010 Vol. 19/No. 4

4 also a preparation for real life. We re going to have administrators that we don t like; we re going to have colleagues that we don t like. Responsibility and trust. Respon - sibility and trust were also commonly reported themes. Respon - sibility was perceived as instrumental in increasing confidence. Establishing trust with instructors, nurses, and patients in the student role was viewed as positive. Participant 1 noted, I think that the most positive experiences I ve had, have been when I was on my own and I felt like I had the responsibility of doing something and I did it. I do things better if I know it s my responsibility to get it done and to do it right and I don t have somebody breathing down my neck even if it s taking staples out or something little. If you can do it and then later someone says, You did a good job on that, but it wasn t because they were right there telling you what to do, it s because you did it and you thought your way through it. That seems to be the most positive experience the more responsibility you have and I guess not freedom, but more trust you have from your instructors and the nurses. Reflection. Participants indicated nurses within the CLE who reflected on their own student experiences and tried to make the CLE experience meaningful for students were perceived as a positive element. According to Participant 4, it was nicer to be with nurses who remembered what it was like to be a student, versus the ones who said, I m so burnt out on students. Different perspectives. Partici - pants also perceived the opportunity to perform or observe skills with a nurse as a positive experience. This perception included the opportunity to gain a different perspective on the performance of a skill as compared to the way they may had learned it from their instructor. Nurses also were viewed as less threatening during skills performance because they were not as familiar with the student as the instructor was. Question 3: What elements of the CLE do student nurses identify as having a negative impact on learning? Participants had many comments about negative elements within the CLE that impacted their learning. Responses ranged from feeling like an annoyance to the staff nurses; lack of skills performance opportunities, such as starting IVs; the vast differences in skill performances among nurses; the lack of assessing student knowledge and experience before delegating a task to them; and nurses confidence level with student nurses. The following perception of a negative element impacting learning in the CLE was identified. Nurses confidence level. Par - ticipant 4: On my last experience, there was a nurse that was charting, and I was looking over her shoulder to see how she was charting and everything and she eventually stopped and she was like, Um I can t do this. And at first it made me uncomfortable, but later when she talked to me it was her insecurity about the new charting system. I think as a student I should be watching her chart and that should be part of my experience. Question 4: To what degree do student nurses perceive that clinical experiences impact their plans for future nursing practice? Participants were asked to discuss what impact, if any, their CLE experiences had on their future nursing practice. A re-occurring theme within the responses centered on technology and nursing documentation. Participants perceived themselves as champions of technology and role models for implementing computer documentation. Their rationalization for this perception stems from the introduction and utilization of computers throughout primary and secondary education levels which increased confidence and comfort levels with technology. Additionally, participants de - scribed their ability to take negative experiences and turn them into positive learning experiences. When asked to think about their future as nurses, participants voiced agreement with the following statement. Participant 1: I think the bad nurses that we ve had the ones that just didn t give a flip about anything have made us better, or want to be better, because you see them and you say, I would never treat my patient like that or roll my eyes because they can t feed themselves. You see the way that they treat people or the way they act or the way they feel and you just think I m sorry for them but I don t want to be like that, and so you want to be better. Question 5: What additional factors do student nurses identify as impacting clinical learning? Skill acquisition. The majority of the participants reported a lack of skill acquisition. At least half of the participants within this study did not have a clinical experience which involved starting an IV or inserting a urinary catheter in a patient. Lab time provided opportunities to practice IV and catheter insertion, and various other invasive procedures. However, participants voiced the desire for more opportunities to perform skills prior to graduation from their nursing program. Participant 1: And I think IV time I would like to have a whole week where all we did was start IVs at a clinic or something. Nursing Implications Participant responses de - scribed nursing as caring, holistic, and empowering. The same was said of what nurses do. Nursing is perceived as a caring profession with nurses acting as advocates and direct care givers. Discussion The results of the student nurses perceptions toward learning in the CLE demonstrates the significance of positive and negative elements within a CLE. The four main positive themes were preceptorship, responsibility/trust, reflection, and different perspectives. The perception of decreased confidence levels of nurses around students was the main negative theme. Chan (2002) indicated relationships among students, peers, instructors, staff nurses, and other members of the health care team are vital in providing an environment that is positive, supportive, MEDSURG Nursing July/August 2010 Vol. 19/No

5 and conducive to learning. Nurses in the role of a preceptor or staff nurse were an influential element with regard to learning in the CLE by student nurses. Regardless of good or bad experiences, participants learned from nurses in the CLE. Results showed student nurses wanted responsibility and trust from nurses, instructors, and patients. Students viewed in - creased responsibility as a confidence builder. Students wanted preceptors who understand the level students are at; and are able, and willing, to provide regular feedback regarding the student s performance (Happell, 2009, p. 375). Nurses who reflected upon their own student nurse experiences were perceived by students as compassionate and supportive toward students. This was perceived by students as increasing a sense of acceptance and support:...ability (of preceptors) to know and appreciate the level of knowledge and the limitations of students theoretical preparation and support as a role model in helping students feel they are safe and valued (Happell, 2009, p. 375). Nurses within the CLE offered different perspectives related to skills performance. These nurses demonstrated a skill procedure that might not follow the exact steps taught in the classroom setting, but achieved the same end results without compromising patient safety or integrity of the procedure. Students acknowledged a difference in theory and practice. Students appreciated the opportunity to participate in nursing activities and learn from observing the practices of more experienced colleagues (Charleston & Happell, 2005). The negative theme of decreased confidence levels of nurses when working with student nurses was acknowledged by the majority of the study participants. According to Matsumura, Callister, Palmer, Cox, and Larsen (2004) nurses may experience professional insecurities if they encounter challenging situations while educating students. The clinical nurse may feel threatened when working with students, yet, at the same time, realize that one s ability to accomplish quality patient care provides a direct mentoring example to the student (p. 301). Assumptions and Limitations of the Research Project The qualitative approach utilized by this study supports the potential transferability of result findings to similar settings. The results of this study are general and transferable to similar undergraduate nursing programs. Draw - backs of this study include participant characteristics (self-selection) and group meetings. Parti - cipant characteristics, such as selfselection, limit the specificity of criteria for participants. It could be assumed participants wanted to vent frustrations rather than contribute to the purpose of the study. The use of group meetings rather than one-on-one interviews was utilized for time management and cost effectiveness. Nursing Implications The re-occurring themes identified by participants as having a positive impact on learning in the CLE were the preceptorship opportunity, acceptance from clinical staff and the ability of nurses to recall their own struggles and perceptions of the CLE as nursing students. Participants identified the desire for compassion, acceptance, and support from nurses. The need for nurse preceptors is critical, and preceptorship or mentoring components should be a part of each clinical rotation if possible. Preceptorship has been consistently acknowledged in the literature as a strategy to maximize the benefits of clinical nursing education in terms of knowledge and skill acquisition, confidence, and professional socialization (Happell, 2009, p. 372). Student nurses also identified potential strategies for enhancing educational opportunities. Student nurses perceptions are significant not only for identifying problems or areas of concern, but also for providing problemsolving strategies. One participant provided the following recommendation for enhancing student nurse learning in the CLE: reverse shadowing. Participant 1: I was just thinking, I had a serving job one time, and I shadowed an employee. Then they started giving me a table or two, a slow transition. Then the last week, they shadowed me. In the hospital setting, as long as it wasn t something life threatening, you could do the same. After you leave the room, ask (clinical instructor or preceptor), Ok, what did you see that I did well, what could I change, what did I forget to do, what do I need to go back and do right now? The topic of student nurse perceptions provides a wealth of information regarding learning in the CLE. As the profession of nursing continues to evolve, the educational experiences and opportunities for learning in CLEs will need further assessment, research, and evaluation. Further research of this topic and other aspects of the CLE and learning is needed. Conclusion This qualitative descriptive study considered the perceptions of one group of student nurses regarding their learning experiences in the CLE. Findings showed nurses are considered role models to student nurses, and the utilization of preceptorship in the CLE enhances student nurse learning. Lastly, of relevance to learning in the CLE is the commitment of nurses to reflect upon their past experiences as novice nurses, acknowledge themselves as role models, and give back to the nursing profession as preceptors. References Benner, P. (1982). From novice to expert. American Journal of Nursing, 82(4), Chan, D., (2001). Development of an innovative tool to assess hospital learning. Nurse Education Today, 21(8), Chan, D. (2002). Development of the Clinical Learning Environment Inventory: Using the theoretical framework of learning environment studies to assess nursing students perceptions of the hospital as a learning environment. Journal of Nursing Education, 41(2), Charleston, R., & Happell, B. (2005). Attempting to accomplish connectedness within the preceptorship experience: The perceptions of mental health nurses. International Journal of Mental Health Nursing, 14(1), continued on page MEDSURG Nursing July/August 2010 Vol. 19/No. 4

6 The Good, The Bad, and The Ugly continued from page 244 Darlington, Y., & Scott, D. (2002). Qualitative research in practice: Stories from the field. Crows Nest, Australia: Allen & Unwin. Dunn, S., & Hansford B., (1997). Undergraduate nursing students perceptions of their clinical learning environment. Journal of Advanced Nursing, 25(6), Happell, B. (2009). A model of preceptorship in nursing: Reflecting the complex functions of the role. Nursing Education Perspectives, 30(6), Massarweh, L.J. (1999). Promoting a positive clinical experience. Nurse Educator, 24(3), Matsumura, G., Callister, L.C., Palmer, S., Cox, A.H., & Larsen, L., (2004). Staff nurse perceptions of the contributions of students to clinical agencies. Nursing Education Perspectives, 25(6), O Connor, A. (2001). Clinical instruction and evaluation: A teaching resource (2 nd ed.). Sudbury, MA: Jones and Bartlett Publishers. Papp, I., Markkanen, M., & von Bonsdorff, M. (2003). Clinical environment as a learning environment: Student nurses perceptions concerning clinical learning experiences. Nurse Education Today, 23(4), Pearcey, P. (2007). Tasks and routines in 21st century nursing: Student nurses perceptions. British Journal of Nursing, 16(5), Polit, D.F., & Beck, C.T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8 th ed.). Philadelphia: Lippincott Williams and Wilkins. Ranse, K., & Grealish, L. (2007). Nursing students perceptions of learning in the clinical setting of the dedicated education unit. Journal of Advanced Nursing, 58(2), Thomas, D.R. (2006). General inductive approach for qualitative data analysis. Retrieved from nductive2003.pdf 246 MEDSURG Nursing July/August 2010 Vol. 19/No. 4