Redesigning clinical education for nursing students and newly qualified nurses: A quality improvement study

Improving student success and retention in first-year nursing through embedded tutor support

BACKGROUND

Nursing students from diverse or equity backgrounds are less likely to possess the required skills to ensure success in their studies. This research explores the impact of embedded support on student learning in a first-year foundational subject, Contexts of Nursing, in an undergraduate nursing degree.t.

METHODS

The Embedded Tutor Program offers specialised tutoring support for first-year undergraduate students. Embedded tutors, with backgrounds as registered nurses and academics, provided online one-on-one feedback to students on draft assessment tasks. Outreach contact was provided to students at risk of failing. A Pearson's Chi-squared test was used to assess the impact of tutor support on grade distribution and a paired student t-test was used to assess the difference in cumulative marks for students from equity backgrounds. Statistical significance was set at p < 0.05. Feedback provided by students, tutors and staff in an online anonymous survey was thematically analysed.

RESULTS

There was a significant grade shift for the 267 students who met with an embedded tutor (p < 0.05). Students who were a member of an Australian Government identified equity group had a significant increase in their cumulative mark if they met with a tutor of 9-17 % (p < 0.05). This improvement in cumulative mark was maintained for students with cumulative equity factors. The overwhelming majority of students who were identified as at risk of failing and met with a tutor following outreach support received a passing grade. Students reported growing skills and confidence in academic literacy was a key benefit of the program.

CONCLUSION

A shared approach to delivering education has a positive effect on the experience of learning. The combined efforts of the subject convenor, embedded tutors, and extended student service roles within the University resulted in outcomes that were positive for student learning. Determining student capacity for learning extended beyond a student's consideration of grades or their progression in the program to include the development of self-efficacy.

Pre-assessment judgement framework for judging nursing students' performance in clinical placements: A qualitative case study

AIM

This study aims to better understand and articulate the pre-assessment judgement processes commonly used by experienced clinical facilitators when assessing nursing students undertaking clinical placement.

BACKGROUND

In the Australian context, clinical facilitators are registered nurses who primarily educate, monitor, support and assess groups of nursing students on clinical placements without carrying a patient load. The duties and scope of clinical facilitators may differ across international and institutional contexts. However, the core concepts of this paper will be relevant despite these differences as the importance of facilitators' confidence in making pre-assessment judgements of individual nursing student performance while on placement is universally acknowledged. Nursing students are often assessed on their provision of safe practice, patient task-orientated outcomes and professional behaviour. Clearly articulating performance judgements prior to formal assessment is vital to ensure progressive learning of students. Literature reports that many clinical facilitators lack confidence in the art of making performance judgements and call for targeted professional training and support in the clinical assessment of nursing students. To better understand and address this problem, clinical facilitators need a shared understanding of how individual nursing students' pre-assessment performance judgements are reached during placement experiences.

DESIGN

A qualitative case study was used, with data collected via semi-structured interviews. Fifteen Australian clinical facilitators participated, each with over six months of experience.

METHODS

Interview transcripts were analysed through an interpretive-constructivist paradigm. Thematic analysis revealed themes that were then deductively described through the application of the Cognitive Continuum Theory.

RESULTS

Six modes of pre-assessment judgement emerged from the data synthesis process: 1) Recognising patterns, 2) Acknowledging uncertainty, 3) Understanding key players, 4) Verifying or refuting the information, 5) Benchmarking performance and 6) Contextualising information. Each mode is validated through the deductive application of the Cognitive Continuum theory.

CONCLUSIONS

Understanding how experienced clinical facilitators make pre-assessment performance judgements has the potential to increase confidence in performance judgement decisions. In turn, confidence in judgements will increase clinical facilitator's capacity to give nursing students feedback that can be explained and justified. The pre-assessment judgement framework also provides a preliminary model for teaching the art of reaching accurate performance judgements to clinical educators in disciplines beyond nursing.

The assessment of undergraduate bachelor of nursing students in the collaborative clusters education model: A qualitative descriptive design

BACKGROUND

Worldwide, undergraduate Bachelor of Nursing students are required to complete experiential learning placements in health care settings as part of the curriculum. There are a variety of facilitation models that support student learning and assessment on clinical placement. As workforce pressures increase globally, innovative approaches to clinical facilitation are required. In the Collaborative Clusters Education Model of clinical facilitation, hospital-employed clinical facilitators work collaboratively within peer groups (clusters) to collectively participate in a process of facilitating student learning and conducting assessment and moderation of student performance. The assessment process in this collaborative clinical facilitation model is not well described.

AIM

To describe how the assessment of undergraduate nursing students is achieved in the Collaborative Clusters Education Model.

DESIGN

A qualitative descriptive approach was employed.

METHODS

In March 2021 individual and group interviews were conducted with seven clinical facilitators working in the Collaborative Clusters Education Model in one health service in southeast Queensland, Australia. Content analysis of transcribed interviews was performed.

RESULTS

Assessment was achieved through two processes, situational scoring and moderation. In the process of situational scoring, clinical facilitators balanced the students' perception of their role in assessment, accounted for the type of experiences available, considered multiple sources of evidence and used the Australian Nursing Standards Assessment Tool. In the process of moderation, clinical facilitators communicated with their cluster colleagues to determine a shared understanding of student history, considered data from multiple evidence sources and collaboratively evaluated the trustworthiness of student performance evaluation decisions.

CONCLUSIONS

In the Collaborative Clusters Education Model, the input of multiple assessors, working in a small team, ensured transparency in assessment processes. Furthermore, this transparency in assessment practices normalised on-going moderation, an in-built quality-check and, as such, an innovative component of assessment in the Collaborative Clusters Education Model. As nursing directors and managers seek to ameliorate the impact of nursing workforce pressures, this innovative model of collaborative assessment may serve as a valuable addition to nursing clinical assessment toolkits.

TWEETABLE ABSTRACT

The Collaborative Clusters Education Model of Clinical Facilitation enables transparency in assessment processes and normalises moderation.

Clinical placement models for undergraduate health professions students: a scoping review

BACKGROUND

Clinical learning is fundamental to undergraduate health professions students. There are several calls for the transformation of health professions education, which have direct implications on clinical learning. Clinical placement models provide structure to clinical learning. Therefore, this scoping review could contribute to supporting curriculum transformation to enhance learning in the clinical environments for undergraduate health professions students.

OBJECTIVES

This scoping review identified the characteristics of research evidence related to mapping the purpose, methodologies used, outcomes, and specific recommendations associated with clinical placement models in undergraduate health professions education.

DESIGN

A scoping review method was used in this study. A search string developed from the title of the review was used to search online databases to identify research published between January 2000 and March 2020.

RESULTS

Forty-eight articles reporting on ten clinical placement models were included in this review. The majority of these articles originated from Australia and predominantly report on nursing. The aims of these articles aligned with the evaluation of the implementation of a clinical placement model. Seven categories of outcomes of the clinical placement models are reported namely, relationships, influence, environment, facilitation, inputs, knowledge scores, and student perceptions.

CONCLUSIONS

As clinical learning is fundamental to undergraduate health professions education, clinical placement models should prioritise the development of competence among undergraduate students. Insights into outcomes reported in literature could guide educators in fostering optimal learning in students who may then be able to influence community health outcomes positively.

The Learning Environment of Student Nurses During Clinical Placement: A Qualitative Case Study of a Student-Dense Ward

Introduction

Ensuring the quality of clinical placements has long been a challenge in nursing education. This is partly due to a growing aging population requiring health services, and an increased need for nursing workforce. Both in Norway and internationally, there is a rise in the use of student-dense models, wherein several students are placed together on the same ward at the same time where the supervision of the students is the collective responsibility of the nurses.

Objective

The aim of this study was to explore factors that promote or inhibit learning in a student-dense ward when used as a model for clinical placement in hospitals. We examined how clinical placement is experienced in a student-dense ward, as well as how learning is facilitated.

Methods

A qualitative case study design was used to capture the learning environment on the student-dense ward in a comprehensive way. We used focus group interviews, in-depth interviews, and observations with students and employees at a major hospital in Norway.

Results

Our findings showed that the orientation days and the teaching activities in student-dense wards, the feedback students receive, the clinical facilitator's role and the student community were factors that had particular importance for good learning environments in this placement model.

Conclusions

To ensure the quality of clinical placements, more attention should be paid to these factors in the planning, organization, and facilitation of new and existing student-dense wards. It is paramount to provide students with thorough written feedback and to secure the clinical facilitators with enough time to conduct student supervision when organizing clinical placement as student-dense wards.

Developing intersubjectivity and teamwork skills through learning circles on clinical placement: A mixed methods study

AIM

To determine the efficacy of learning circles on developing intersubjectivity and teamwork skills and determine barriers to and facilitators of, learning circles as a learning tool.

BACKGROUND

Teamwork skills are vital for safe, effective nursing care and are dependent on individual team members' shared understandings or intersubjectivity. Work-based learning circles offer a potential pedagogic strategy to promote teamwork.

METHODS

In work-based learning circles conducted in 2018, students drew a concept map based on a clinical case and discussed an element of it with the group. Using a convergent parallel mixed methods design, a cross-sectional survey of students using a student clinical experience questionnaire and a qualitative descriptive approach for interviews with clinical facilitators was conducted.

RESULTS

Overall, 128 Bachelor of Nursing students (88.9% response) completed the survey and five facilitators (50%) attended group interviews. Students agreed that core teamwork skills were developed during their placement and clinical facilitators reported (1) student engagement in the learning circle processes; (2) learning much about students' abilities; and (3) developing subtle teaching skills to enhance discussion. Sharing experiences from different wards and clinical experiences was a platform for developing intersubjectivity.

CONCLUSIONS

To promote intra-professional teamwork skills, conducting learning circles with students from different disciplines may further enhance intersubjectivity and is an area for further research.

Interventions to support graduate nurse transition to practice and associated outcomes: A systematic review

OBJECTIVE

The aim of this mixed methods systematic review was to: i) document the interventions that support and facilitate graduate nurse transition from university to practice in a diversity of healthcare settings and ii) to identify outcomes from graduate nurse transition interventions for the graduate, patient or client, and health service.

DESIGN

This mixed methods systematic review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. All quantitative, qualitative, and mixed methods studies were included if they met the inclusion criteria.

DATA SOURCES

Primary research studies located in Medline, EmBase, CINAHL, Prospero, Cochrane Library, PsycInfo, and Web of Science (Social Science Citation Index). All quantitative, qualitative, and mixed methods studies were included if they met the inclusion criteria.

REVIEW METHODS

Using a comprehensive search strategy, retrieved articles were screened by two reviewers at the title, abstract, and full-text stage. Reviewer disagreements were discussed until consensus was achieved. The well-validated Mixed-Methods Appraisal Tool was used to assess quality of the quantitative, qualitative, and mixed methods studies.

RESULTS

A total of 130 studies were included as the review dataset. There was a myriad of terms used to describe transition interventions, and programme length and settings varied. The content of transition interventions was not well defined, and there was a lack of studies outside acute hospital settings. Data collection methods varied widely. The majority of authors reported outcomes for the graduate or the graduate and service, with only one reporting outcomes for the patient or client. There was a significant variation in quality across the studies.

CONCLUSIONS

This review addresses a significant gap in the literature by documenting transition interventions in a diversity of health settings and outcomes from these interventions. Interest in transition to practice continues to rise, but there is an urgent need to conduct well designed, robust, and larger-scale studies at the national and transnational levels.

Undergraduate nursing student and preceptors' experiences of clinical placement through an innovative clinical school supervision model

This study explores final year undergraduate nursing and midwifery students and their preceptors' experiences of a newly introduced Clinical School Supervision (CSS) model, which was implemented to reduce a perceived disconnect between theory and practice. A descriptive design was used with qualitative data collected through open-ended survey questions. Respondents included 43 undergraduate nursing and midwifery students involved in the final year and 13 clinical preceptors from a large metropolitan tertiary health service in Victoria, Australia. Qualitative data were analysed using thematic analysis. Students described the CSS as a favoured supervision model with students being able to take advantage of support from both the academic supervisor and nursing staff in the clinical setting, a model which also supported student's sense of belonging. Students experiences indicated the CSS model facilitated consolidation of knowledge, reflective practice and transition to graduate nursing. The preceptors described a commitment to and preparedness for the role, although they found they had little break from teaching and their rosters did not always align with their students'. Preceptors also shared experiences of unfulfilled expectations, lack of recognition and incentives for supervising students. Further studies are needed to identify effective ways to support preceptors in their roles.

Supporting culturally and linguistically diverse (CALD) undergraduate nursing students undertaking clinical placements in Australia: An exploratory qualitative study of clinical facilitator and CALD student perceptions

BACKGROUND

Internationalisation of higher education has contributed to the increasing number of culturally and linguistically diverse students in higher education programs worldwide. While there is some literature on the experiences and needs of these students, there is little evidence on what resources can be used to support these students when learning in the clinical setting.

AIM

This study aimed to evaluate the usefulness of an existing handbook developed for clinical facilitators to enhance culturally and linguistically diverse nursing students' learning, and to explore the facilitator and student perceptions of their clinical placement support needs.

DESIGN

This exploratory qualitative study, involving culturally and linguistically diverse Bachelor of Nursing students and clinical educators, was conducted in a multi-campus School of Nursing and Midwifery at Griffith University, Australia, in collaboration with health services. Focus groups and individual interviews with clinical facilitators and culturally and linguistically diverse nursing students were conducted. Activity theory provided the conceptual framework for this study and the qualitative data analysis was informed by grounded theory.

RESULTS

Clinical facilitator focus groups and interviews generated three themes: understanding culturally and linguistically diverse students' needs; supporting culturally and linguistically diverse students; and improving learning resources for facilitators and students. Student focus groups generated three themes: wanting to be more prepared for clinical placement; feeling supported by facilitators and interacting with others in a different context; and creating resources to support learning.

CONCLUSIONS

Supportive clinical environments are key to the work-integrated learning success of culturally and linguistically diverse nursing students. The findings of this qualitative research study, involving clinical educators and culturally and linguistically diverse Bachelor of Nursing students identify the pressing need to develop readily accessible resources to support the clinical learning of culturally and linguistically diverse students and their educators. Resources development should be attentive to complexities at the intersection of workplace culture and students' developing understanding.

Through the looking glass: the rabbit hole of reflective practice

Reflective practice is a common feature of nurse education. Indeed, the development of nursing practice is associated with being a 'reflective practitioner'. However, how we see ourselves or interpret past events is often influenced by our own unconscious biases. While it is reasonable to hold favourable views of one's ability, biased or lack of self-insight might mean that one is actually unskilled and unaware of it. In the ambiguous clinical context where an act or omission can have potentially devastating consequences, the implications of this are significant. The questions of whether and how reflection addresses unconscious biases are relatively unexplored in the nursing literature. Given that accurate self-assessment is integral to reflective practice, this article attempts to explore the potential impact of unconscious bias on reflection. The authors conclude that while biases may limit our ability to learn from reflection, this is not a reason to dispense with reflective practice, but rather, is even more reason to critically engage with the process. Nurses of all levels must be encouraged to reflect on both their practice, and their reflection.

Supporting Australian clinical learners in a collaborative clusters education model: a mixed methods study

Background

Nursing student numbers have risen in response to projected registered nurse shortfalls, increasing numbers of new graduates requiring transitional support and pressure on clinical placements. A Collaborative Clusters Education Model, in which Entry to Practice facilitators coach ward-based registered nurses to support students’ and new graduates’ learning, may address placement capacity. The research aim was to evaluate the acceptability of the Collaborative Clusters Education Model to stakeholders by examining their perceptions of the facilitators and barriers to the model in its implementation.

Methods

A convergent mixed methods evaluation approach was adopted. The study took place in a large Australian health service in south-east Queensland. Participants included Bachelor of Nursing students, Entry to Practice facilitators, ward-based registered nurses, academics and new graduates. A mixed methods design was used. Elements included an online survey of nursing students, and interviews with new graduates, Entry to Practice facilitators, ward-based registered nurses, and academics. Descriptive statistics were calculated on quantitative data. Thematic analysis was conducted on qualitative data.

Results

Participants included 134 (of 990) nursing students (response rate 13.5%), five new graduates, seven Entry to Practice facilitators, four registered nurses, and three nurse academics. Students rated facilitators’ effectiveness highly (4.43/5 ± 0.75), although this finding is tempered by a low response rate (13.5%). For learners, the model provided access to learning experiences, although preferences for sources of support differed between students and new graduates, and further clarification of responsibilities was required. For other stakeholders, three themes emerged: students’ and new graduates’ integration into the workplace can promote learning; tensions arise in new ways to approach performance assessment; and aligning expectations requires high levels of communication.

Conclusions

This evaluation found that acceptability was good but at risk from limited clarity around roles and responsibilities. Further research into this model is recommended.

'There need to be a balance': Mental health nurses' perspectives on medication education in university and clinical practice

Working with medication is an important role of the mental health nurse. However, little research has focused on staff nurses' perspectives on where the responsibility lies for preparing student nurses for safe, competent medication management. This study investigated mental health nurses' perspectives on medication education. An interpretive descriptive approach was used. Two focus groups were conducted, and data were analysed using inductive content analysis. It was found that participants embraced a medical approach to servicer user care, with less positive attitudes demonstrated towards psychosocial approaches. There were also tensions expressed between clinical practice and the university, with uncertainty voiced about whose responsibility it was to educate students about medication management. It is important that both environments complement each other in order to enhance the student nurse educational experience. While mental health nurses should be educated in this area to practice in a safe and competent manner, it is also key that a holistic approach to care is considered.

Collaborative Learning in Practice (CLIP): Evaluation of a new approach to clinical learning

BACKGROUND

There are challenges in creating positive clinical learning environments. A new model of practice learning for pre-registration nurse education was pilot-tested in the East of England. The Collaborative Learning in Practice model (CLIP) was developed from a similar model of practice learning used in the Netherlands.

OBJECTIVES

We undertook an evaluation of a new approach to clinical learning. The aims of the project were to consider the challenges of implementation; consider the perception of gains and losses of students and stakeholders experiencing the new model of practice learning; and consider the sustainability of the new model in the context of service delivery.

METHODS

Mixed methods were used. Data were collected in three forms: (1) a survey of students undertaking the CLIP model and those learning within the existing mentorship model to assess the supervisory relationships and pedagogical atmosphere experienced; (2) student focus groups; and (3) qualitative one-to-one interviews with key stakeholders in the provision of practice learning environments.

RESULTS

A total of 607 questionnaires were returned out of the 738 distributed, five focus groups of a total of 30 students were undertaken, and 13 stakeholders were interviewed. Students who had experienced CLIP reported lower supervisory relationship scores compared with those without experience (mean difference = -0.24 points, 95% CI -0.21 to -0.094, p = 0.001). There was no difference in pedagogical atmosphere scores (mean difference -0.085 points, 95% CI -0.21 to 0.040, p = 0.19). Analysis of qualitative data produced two themes: 'Adapting the environment' illustrated the importance of learning context and 'learning to fly' highlighted the process of students gaining greater autonomy.

CONCLUSION

Our findings suggest that collaborative learning in practice offers many benefits as an approach to clinical learning but with important caveats. Attention needs to be paid to particular aspects of the model such as sufficient numbers of students, and an acknowledgement of perceived losses as well as gains.