Educators effort in planning for Clinical Education for Nursing Student in educational and clinical settings. And how to toady’s students perception about clinical education and learning.
The Clinical Education for Nursing Student
Over the years, faculty strived to design a curriculum that will prepare the novice nurse to meet the health-care needs of society. Educators have been innovative in developing courses aimed to produce successful learning outcomes. Educational technology and active teaching/learning strategies have been incorporated into the classroom setting. Although dramatic changes have occurred with the classroom setting, clinical education has remained somewhat stagnant.
Clinical education is defined as “the integration of knowledge and skills associated with patient care” (Scholtz, 2000). Experienced nursing faculty members will agree that the basic model for clinical education has remained static for the past 25 years or longer. For example, students (approximately 8 to 10) are assigned to a faculty member for a clinical rotation. Typically, the day before the experience, the instructor assigns each student to approximately two patients in the acute care setting.
Students research the chart of each patient and document pertinent information. The student memorizes medications, reviews pathophysiology, and designs a nursing plan of care. The day of the experience, the instructor quizzes each student on the information. Basically, the student repeats information from the chart or memorized knowledge. During pre-conference, as one student is being questioned, the remaining students are anticipating questions they may be asked by the instructor.
The students proceed to deliver nursing care and regroup at the end of the day for post-conference. Again, the student basically remains focused on the individual assignment. By consistently assigning a student to one or two patients per week, instructors put a limit on the number of situational experiences that may arise; thus, opportunities for clinical judgment are limited. In addition, the clinical experience remains prescriptive and static.
The instructor’s primary function becomes that of a supervisor of procedures as opposed to a facilitator of learning. The amount of critical thinking or clinical judgment that occurs during the course of the day is questionable. As the number of students in each clinical group increases, the amount of time available to engage in meaningful discussion and inquiry decreases proportionately .
Clinical Education for Today’s Nursing Student
Although this model of clinical education may have sufficed in the past, clinical education must be revised for today’s nursing student. Unpredictable client needs, early discharge, and limited available clinical sites require the student to integrate knowledge more efficiently.
Redesign pre- and post-conferences
Because one learning outcome of pre-conference is to broaden the knowledge base and awareness of all students, weekly clinical rounds may be incorporated. This technique has been used in medicine for years and encourages students to assume an active role in decision-making. Instead of purging memorization of knowledge, the instructor can facilitate learning at the application level of learning.
Students have the opportunity to know the patients’ clinical picture in a particular zone as opposed to the one patient assigned to them. Their knowledge base is broadened and the experience offers additional dimensions. At the risk of sounding blasphemous, daily post-conferences may be a thing of the past. In lieu of post-conference, the student may be given an alternative forum to process the events of the day in a group setting.
Asynchronous dialogue allows the student to document his insights, feelings, or thoughts on a password-accessed website that is established specifically for the instructor and students. Students are encouraged to post responses to the logs of their peers.
Internet relay chat (IRC) can be used to set up synchronous chat rooms for the students. Students enter the room using a specific password at a designated time and can join ongoing dialogue. They can share their experiences with their clinical group or nursing students from other schools. The benefit of this strategy is that students can participate from the comfort of their rooms and actively engage in dialogue. A time can be set that is convenient for everyone and not necessarily at the end of an arduous clinical day.
Clinical Preceptors
The use of preceptors is not a new concept in nursing education, but the value of the strategy may have gained popularity. Instructors, who teach on a clinical unit but are not employed as nursing staff on the assigned unit, are basically “guests” on the unit. They are not as vested in the outcomes of the unit because they are generally instructing students for 1 or 2 days per week. With rising enrollment and high numbers of schools rotating through the same clinical sites, their engagement in the matters of the unit is limited.
Students, assigned instead to a preceptor who works as a professional nurse on the assigned unit, can learn from a permanent member of the unit. The preceptor can exercise independent decision-making that the nursing student can observe. Collaborating with a nurse preceptor in the care of four to six patients gives the student greater exposure to a variety of clinical scenarios.
Students could also have increased flexibility. For example, the senior nursing student may be assigned to schedule clinical hours with the preceptor on an evening shift or weekend. This schedule would allow the student to see the variations that occur within the unit and clinical practice on different shifts. In order for preceptor ships to be effective, the potential preceptors should be interviewed.
The nurse should embrace the philosophy of the nursing program and not approach the experience with the perception, “This is how I was taught…so this is how I will teach!” Before the screening, a specific list of criteria should be designed to select a qualified preceptor. It is imperative that the nurse enjoy working with students and respect their learning needs.
A letter of recommendation from the nurse manager or an instructor who has observed the nurse’s interactions with students may be required. It is important to realize that many nurses are experts in clinical practice but novices in nursing education. Once an individual preceptor is selected, the instructor/faculty member should serve as a mentor to the newly assigned clinical instructor. Through the collaborative efforts of the expert instructor and preceptor, successful learning outcomes can be achieved.
Student Perception of Clinical Education
Clinical education is a vital component in the pedagogy of nursing education and students anxiously await their first experience caring for a patient. The need to prepare nurses to provide holistic nursing care and to manage both complex problems and psychosocial issues is inherent within the scope of clinical education.
Complicated procedures, nursing care plans, complexity of disease processes, and interrelationships with families and members of the health-care team are often stressful to the nursing student. Individual differences and appraisal of the clinical learning environment may have an effect on whether students assess clinical experiences as either a challenge or a threat (Lazarus, 1999).
Lazarus (1999) suggested that each person interacts differently with the environment; Therefore, relational meanings of environmental stimulus are unique to the person. The nursing student who appraises the clinical experience as challenging has the potential for growth and mastery. Conversely, the student who appraises clinical education as a threat has the potential for stagnation and failure (Lazarus, 1999).
According to Scholtz (2000), critical attributes of threat include negative cognitive perception, future oriented, negative affective emotions, and the potential for harm. Threat triggers feelings of uncertainty, worry, and distress. The student who feels threatened may experience a threat to self-integrity, immobilized coping, and altered self-esteem (Scholtz, 2000). Challenge is the perception and anticipation of positive outcomes associated with a stimulus (Lazarus, 1991).
A perception of challenge facilitates the student’s desire and ability to perform and learn. Challenge is the opposite of threat. Threat apperception is the person’s assessment of stimulus and the attribution of meanings and consequences to the threatening stimulus (Lazarus, 1999). According to Neuman’s systems model, repeated stressors, such as perceived threat, can cause instability within the person (Neuman, 1995).
Tension-invoking stimuli have the potential to cause situational crises and may jeopardize the student’s success within the educational program (Neuman, 1995). Learning within this context may be jeopardized in students who perceive clinical education as threatening (Kleehammer, Hart, & Keck, 1990). Because the quantity of time devoted to clinical education is limited, the quality of the experience must be maximized in order for the learner to have successful outcomes.
Recognizing that clinical education may be inherently stressful to students, nursing educators attempt to create an environment that enhances learning and promotes professional and personal development of the nursing student (Biggers, Zimmerman, & Alpert, 1988). Rather than intervening when the student is in crisis, perceived threat and performance anxiety could possibly be circumvented through prevention as intervention.
Characteristics of nursing students prone to stress related to clinical education have been studied with varying degrees of reported success (Beal, 1988; Godbey & Courage, 1994; Russler, 1991; Williams, 1993). The profile of a typical student prone to anxiety and stress is a conscientious and hard-working individual (Meisenhelder, 1987). The individual invests long hours in preparing for the clinical education experience and appears overly prepared. However, the student becomes intimidated when questioned by the instructor.
Consequently, the true abilities of the student may be blocked by threat, which manifests as performance anxiety. According to Williams (1993), the nursing major may be the most threatening of all academic majors in college due to its multidimensional nature. In an attempt to discover the threats inherent within nursing, Williams (1993) conducted a descriptive correlational study.
Students identified fear of harming the patient and learning clinical procedures as concerns. These fears may be preconceived by the student; nevertheless, they are perceived as very real. Feelings of threat can be manifested during the initial clinical experience and persist throughout progression through the curriculum. One student may fear the “unknown” of the community experience; whereas, another student fears the high technology of the intensive care units.
Because the amount of time dedicated to clinical education is at a premium, nurse educators strive to use this time to maximize learning. Rather than take a reactive stance to students’ needs and intervene after the stress has occurred, a more proactive approach may be to intervene in order to prevent the stress. A student who is threatened by the demands of clinical education may feel incapable of performing necessary skills. As a result, the context of the situation is the perception of a negative outcome and failure.
Instead of working within the present framework of completing the task, concentration is focused on failure to succeed. One goal of nursing education is to promote a learning environment that is perceived by students as safe and nonthreatening. This goal may be accomplished through prevention as intervention. Neuman (1990) defines primary prevention through intervention as an action that occurs before a reaction to a stressor.
Williams (1993) made a critical recommendation that the initiation of preventive measures that address the high levels of stress experienced by nursing students may enhance student learning and promote successful outcomes. According to Pennebaker’s expressive writing paradigm (1997), writing about an emotional experience decreases feelings of inhibition and promotes self-disclosure of thoughts and fears.
The student who worries about an upcoming clinical experience can release and address these threats through expressive writing. Scholtz’s theory of reframing threat apperception also addresses the use of expressive writing as a method to facilitate positive learning outcomes .
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