Vol.7, No.2 July 2001
Editorial | Contents
Undergraduate Clinical Education in The "REAL WORLD"
Refereed Paper
Authors
Dr Moya Conrick
School of Nursing, Griffith University
Nathan QLD 4111 Australia
Phone 61 7 387 57986; Fax: 61 7 387 57984; Mobile: 61 7 0408 051 248
email: M.Conrick@mailbox.gu.edu.au
Nikki Lucas
School of Nursing, Griffith University
Nathan QLD 4111 Australia
Alison Anderson
Waiariki Polytechnic
Rotorua, New Zealand.
Abstract
This paper explores some of the major factors impacting on clinical undergraduate programmes in nursing and the relative merits and limitations of three different models of facilitating learning in clinical settings that is the external facilitator; internal facilitator; and preceptored placements. There is a recognition that the factors impacting upon the two key parties (university based schools of nursing and clinical agencies) reflect broader trends which will continue to make the provision of effective clinical programmes difficult. This paper draws on feedback from health agencies and students as well as the experience of faculty, to illustrate the need for nursing to confront these challenges and to address the issues raised if our high expectations of graduates are to be maintained.
Nursing undergraduate courses must ensure that students emerge from programmes with the expertise and skills to function at a competent beginning practitioner level. This poses significant challenges for nursing educators faced with learning to work more flexibly, effectively and efficiently with fewer resources as funding contracts both in the on and off-campus settings. The over-enrolment of undergraduate nursing courses by universities compounds the problem and places the lecturer in an invidious position - to serve the good of the profession while placating the master and supporting the student body. While student numbers may be problematic on-campus there are also major implications for clinical programmes in the hospital sector where shortages of registered nurses, downsizing, early discharge and expansion of community based care are a reality.
Professional education is seen to be a "bridge between the world of thought and the world of action" (Fahey, cited in Lumby 1989 p. 297). If clinical learning is to provide that link for student nurses as Lumby suggests, then the onus is on the nursing profession to provide the experience, stimulus and support necessary for learning to occur. Although the majority of nurses would agree with these sentiments, and strive to do their best by the profession, in practice quality placement for students and rich clinical learning experiences are becoming more elusive.
Universities have never found it difficult to fill nursing places partly because of the lower entry score for nursing in comparison to other courses leading to professional qualifications. Many schools of nursing have been attempting to lower student numbers for many reasons including the difficulty in placing and funding undergraduate students’ clinical practicum. Despite this, some universities persist with over enrollments, exerting pressure on both on and off-campus clinical placement areas.
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Paradoxically, while student over enrollment is problematic, the lack of experienced registered nurses also impacts on the quantity and quality of the clinical placement. This lack of experienced registered nursing staff, early discharge of patients, downsizing of institutions, under funding of nursing in both hospital and community settings are well-documented facts of the modern health care industry. However, when these are coupled with the difficulties of marrying student learning objectives to placement areas and restrictive semester timetables, the planning of meaningful clinical practicums becomes more complex. The necessity for institutions to accommodate other clinically focused health disciplines and post-graduate students further compounds these problems creating a 'traffic jam' of student undertaking clinical placements.
A survey of twenty health agencies identified the peak times for placement requests were from March to November (Senior Nurse Academic Forum, 1998). Half of the agencies expressed concerns over their ability to meet university placement requests in the future and suggested spreading clinical placement throughout the year to avoid peaks and troughs. Although this may provide a solution for one problem it may create another. December to February is the period during which many agencies have extended periods of ward closures and theatre downtime, would we sacrifice placement quality for quantity. Pragmatically spreading clinical placements may also lead to fragmentation of learning and expand the theory practice gap.
When planning a clinical practicum the setting is scrutinised to ensure that it affords students the opportunity to practice in their immediate area of learning. Although this is an ideal situation, which creates a meaningful platform for integrating theory and practice, realistically, it cannot always be achieved. Not surprisingly, the most sought after placement for undergraduate students is the medical/ surgical area, but most institutions identified this area as over utilised. On the other hand, areas of specialty, for example aged care, maternity, high dependency areas (theatre, coronary and intensive care), community health and mental health were thought under utilised (Senior Nurse Academic Forum 1998). Conflicting messages emerge from this forum: whilst speciality placements were perceived to be under utilised the same representatives acknowledged that student access was restricted in some speciality areas. The restrictions might be on all students; undergraduate students only; or priority given to postgraduate students in preference to undergraduate students. Of the organisations represented at the forum 60% restricted access to speciality areas. 50% of all organisations denied all students access to some speciality areas (Senior Nurse Academic Forum 1998). Another compounding factor in placing students, is the necessity for agencies to withdraw wards or entire placements at short notice.
Clinical practicums are not independent components of an undergraduate course. Infante (1989), showed that synchronisation of clinical laboratory experiences, nursing theory and science and a closer collaboration among faculty, students, and nurse practitioners gives students an appropriate balance of academic and clinical practice perspective and skills to prepare them effectively to meet clients’ health care needs. This is something that Schools of Nursing strive for and deem essential for student growth.
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The clinical experience must be kept relevant, interesting and motivating with two major components of instruction: educational methods and educational activities. White and Ewan (1991, p 5) caution that "it is usually taken for granted that students will learn clinical skills 'by doing' on clinical practice" as if clinical learning was an automatic process. However, clinical teaching is much more complex than this. It is the task of the clinical teacher to facilitate learning by providing opportunities for learning through observation, thinking, reflection and by practicing clinical skills. Within the profession there tends to be a failure to recognise the skills and attributes of effective clinical facilitators.
Just as clinical practice is not automatic for the student, teaching is not automatic for the clinician. White and Ewan (1991) regard the assumption that an expert clinician ensures that a person is an expert teacher as floored. This becomes an issue when deciding on the approach and use of a model of clinical education. Three models dominate clinical practice: the external facilitator model, the internal facilitator model and the preceptor model.
The external facilitation model uses experienced nurses, ideally with an educational qualification and experience, who are orientated to the curriculum and able to integrate educational principles into the clinical practicum. The facilitator to student ratio is usually one: eight. However, agencies (Senior Nurse Academic Forum 1998) and students (Survey 1996) perceive that external facilitators lack adequate knowledge of the particular institutional setting. Nevertheless, students also cite external facilitators' independence of the agency as valuable in maintaining a student centred approach to learning.
Although the external facilitation model is most frequently utilised in agencies with the independent facilitator generally supervising, mentoring, supporting and enhancing the practicum, students impose an additional load on the agency clinician both physically and emotionally. In this facilitation model, the facilitator often works with students dispersed over several wards, making it impossible to oversee each student at all times throughout the practicum. Another of the shortcomings of this model is the inability of universities to provide continuous employment and a clear career path for this group of highly motivated and qualified nurses.
On the other hand, the internal facilitator model uses a facilitator who is employed by the agency and is familiar with the setting. They also use the ratio of one facilitator: eight students. This model was the preferred option by most participants at the Senior Nurse Academic Forum (1998), as they regarded internal facilitators as not only clinically competent, but also familiar with and committed to the agency. Nevertheless, the closeness of this relationship with the agency may generate problems, because unlike the external facilitator, whose primary concern is the student practicum, the internal facilitator may lose this student focus essential for effective clinical placement. Another consequence of this model is the potential for staff burnout when appropriately qualified and experienced staff is over used.
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The third model of facilitation is preceptorship, in which, an experienced registered nurse is paired with a student, in a one-to-one situation, for the duration of the clinical learning experience. Agencies thought this advantageous (Senior Nurse Academic Forum 1998), regarding local knowledge as providing for easier facilitation. They considered that with this model students’ learning was enhanced, because they gained greater access to multiple clinical situations and learning experiences, they had increased involvement in the clinical area and had access to a greater range of clinical expertise. However, agencies revealed that the preceptorship model increased demand on staff leading to burnout, that it was expensive for the facility and that the preceptor was probably not up to date on adult learning, learning activities and strategies (Senior Nurse Academic Forum 1998).
A student survey indicated that some enjoyed the experience of preceptorship although they felt that they did not really ‘fit in with the camaraderie of the ward’. Others felt unsupported and suggested that the preceptor model was most likely to work with third year students or more independent learners able to identify and negotiate to meet their own learning objectives. There seems to be a popular myth that students can be introduced to the 'real world' of nursing through preceptorship. However, this notion would seem to have its roots in the defunct world of the nursing apprenticeship approach to nursing education. It also fails to recognise the complexity of the clinical situation and the challenge of educational process.
Quality learning in the clinical setting is dependent on many factors, for example the student maintaining a peripheral role as students of the profession not workers within the profession. It also depends on the quality of facilitation and the abilities of the clinical teacher. Access to multiple clinical situations and learning experiences are also necessary for quality learning experiences. These should not be dependent on or hindered by the facilitation model in pace, but rather on the goodwill of the agency and clinicians to nurture future practitioners. Although many agencies accept their obligations to the profession, the registered nurse shortage and availability of student mentors impacts greatly on the undergraduate clinical practicum.
Institutions have found that, with the restructuring of nursing, many of their experienced and expert nurses have left the bedside; some have chosen to leave nursing. The shortages have left an undermanned, inexperienced and sometimes unsure workforce. Consequently, students may be mentored by nurses with not a great deal more experience than they may have. In some aged care settings, enrolled nurses (EN) are entrusted with mentorship of first year students although there are quite marked differences in the behaviour expected by the EN and the beginning RN. Universities and nursing expect students to be mentored by clinicians at an appropriate level, but fail to specifying the meaning of appropriate. However, a broad educational role is identified in the job descriptions of level two nurses.
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Staff burnout, can become a significant problem for agency staff with most institutions hosting students throughout both semesters. Many students are assigned to the three shifts, and staff often mentor students from more than one university in a day. In light of the discussion above, it could be argued that one of the greatest challenges facing the profession is the development of a model of clinical education, which provides educationally sound clinical placements in the face of current constraints. However, there is limited research into the educational efficacy of the different models of clinical education currently adopted and outlined earlier in this paper. Therefore, there is a danger that economic constraint, rather than educational principles, will determine the models adopted in the future.
Nursing education has the primary objective of producing competent beginning practitioners, but sometimes the realisation of an educative experience is difficult to achieve in the practice setting for pragmatic reasons and extraneous issues that seem difficult to control. A common issue is communication breakdown, which appears simple to address, but in reality is difficult to overcome. Very often the university facilitator on a pre-clinical visit finds the clinician unaware of and unprepared for the practicum and the studentsí educational needs. Although a briefing is held with staff and mentors arranged, this is often fruitless, because the staff complement or timetable has changed or for some reason the clinician briefed for the visit is unavailable.
Other factors impacting on universities and the clinical setting may not have the same major impact as the choice of a clinical learning model, but nevertheless require a clear directive from the profession. It is beyond the scope of this paper to discuss them fully, but a few examples are advanced.
Nursing is confronted by the dilemma surrounding the admission wheelchair bound students and those who are profoundly deaf, because students with disabilities cannot be excluded from university according to the Disabilities Services Act. Although these students are mentally competent, and committed to the profession, the issues for clinical practice are immense. This is a universal issue that has been robustly debated in the electronic media with our colleagues in South Africa and the United States, but finding an equitable solution is elusive. Other issues such as drug dependence or criminal record and generally, the suitability of students to undertake clinical practice and ultimately enter the profession also arise: from a University perspective, they cannot be excluded, but again professional guidelines are inadequate.
The questions and issues raised in this paper must be addressed and can be solved if the profession has the will to do so. The divide between faculty and clinicians needs to be overcome. However, this problem has been ongoing for many years, predating the move to universities. It will require much goodwill by all parties if solutions are to be found.
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List of References
Griffith University (1996). Student evaluation of clinical practicum. Unpublished data.
Infante, M. (1988). The challenge of clinical teaching for nurse educators, The Clinical Laboratory in Nursing Education (2nd ed.,). New York: John Wiley and Sons.
Kermode, S. (1985). Clinical supervision in nurse education: some parallels with teacher education. Australian Journal of Advanced Nursing, 2(3), 39-45.
Lumby, J. (1989). Preparation for practice. In G. Grey & R. Pratt (Eds.), Issues in Australian Nursing 2 pp 291-310. London: Churchill Livingstone.
Senior Nurse Academic Forum (1998). Survey of clinical agencies response to student clinical placements. Unpublished data.
White, R., & Ewan, C. (1991). Clinical Teaching in Nursing. London: Chapman and Hall.
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Last modified on: Monday, 23-Jul-2007 10:56:01 EST
