Enhancing nursing students\' clinical placement experiences: A quality improvement project

How can the clinical placement experience of nursing students be improved?


An exploration of the perceptions of clinicians and nurse managers.




Introduction

The National Review of Nursing Eduction identified the need to improve the
quality of nursing students' clinical education as a matter of some urgency
(Heath, Duncan, Lowe, Macri, & Ramsay, 2002). In this paper we address this
important professional issue from the perspective of clinicians and nurse
managers. It is critical that we focus on improving the quality of clinical
learning as students often find their clinical placement experiences
difficult and stressful (Elliot, 2002; Timmins & Kaliszer, 2002). They
describe feelings of alienation, a lack of sense of belonging, and fear of
making mistakes. These feelings often lead to insecurity and anxiety that
no doubt impedes learning (Crawford & Kiger, 1998; Goh & Watt, 2003;
Meisenhelder, 1987).

In response to these concerns the University of Newcastle recently
appointed two clinical liaison nurses to undertake a quality improvement
project. The project began by seeking clinicians' perspectives of how the
clinical learning experience of nursing students could be improved. This
paper presents an overview of the issues related to clinical learning and
outlines the qualitative data collection and analysis methods used in the
project. The problems associated with clinical learning identified by
Registered Nurses and their recommendations for improvement are then
described. Finally the paper outlines the changes that have been
implemented as a result of this project and discusses future directions to
maintain and enhance the quality of clinical education.


Purpose of the project

The quality assurance project that is described in this paper was
undertaken because:

(a) There is evidence, both anecdotal and empirical, that suggests that
students' clinical experiences are fraught with problems;

(b) We wanted to explore clinicians' perceptions of these problems and
their recommendations for improvements; and

(c) Where feasible, we planned to implement the recommended changes in
order to improve the quality of nursing students' clinical education.


Background

Twenty years following the decision to transfer nursing education from
hospitals to the higher education sector it is not unusual for clinicians
still to suggest that nursing students do not assimilate into the clinical
environment as quickly and easily as had their hospital trained
counterparts (Burns, 2004; Johnson & Preston, 2001), and the transfer to
the tertiary sector, the much-anticipated panacea for the problems of the
nursing profession continues to be questioned (Greenwood & n'ha Winifeyda,
1995). Some venture to suggest that, in reacting to the rigid hospital-
based training system the pendulum has swung too far in the opposite
direction, supporting a system of liberal education that produces poorly
prepared nurses who are often unable to practice in the clinical setting
(Levett-Jones & Fitzgerald, In press). Conversely, universities claim to
provide a broad and comprehensive preparatory education that develops
'beginning' rather than expert practitioners, who are critically
reflective, committed to lifelong learning and are 'competent' according to
the Australian Nursing Council National Competency Standards for the
Registered Nurse (ANMC, 2002).

There is some confusion about the term 'competence' however with some
nurses regarding it from a narrow perspective as the ability to perform
particular clinical skills. Competence has been more accurately defined as
the 'ability to demonstrate an appropriate level of professional practice
in a variety of contexts' (Girot, 1993). This view of competence involves
the ability to combine skills, knowledge, attitudes, values and beliefs
appropriate to professional service delivery and it is this definition that
underpins contemporary nursing curricula (Levett-Jones, Little, & Bujack,
2005). The development of students' clinical competence is a responsibility
that must be shared between university and clinical partners. However
differing points of view between the university and health care sectors can
sometimes be oppositional and lead to entrenched positions where dialogue
is difficult and often avoided.

The quality assurance project described below was explicitly designed to
avoid entrenched and oppositional positions and instead facilitated open
and honest communication. This approach is consistent with Greenwood's
(2000) suggestion that partnerships that are positive and productive view
nursing education as a joint 'health sector' – 'education sector'
enterprise. It was critical, we believed, to strengthen our partnership
with clinicians because students all too often find themselves the losers
in the 'faculty-staff-student triad' and the development and maintenance of
a good working relationship between clinical staff and nursing faculty is
crucial to the development of good clinical learning environments. This
view is consistent with the National Review of Nursing Education (Heath et
al., 2002) that encouraged partnerships in clinical education but cautioned
that:.
'The development of partnerships takes time, hard work and commitment.
In particular, there is a need for the partners to be open about their
agendas and to try to understand where each of the partners is coming
from. In addition, it is important that each partner is treated equally
and that all partners have a clear role within the project'.
Most nurse leaders agree with the importance of partnerships and many
emphasise the need for nursing leadership from both sectors (Chalmers,
Swallow, & Miller, 2001; Clare, Edwards, Brown, & White, 2003; Crookes,
2000). Linden (2002) and Waddock (1988) suggest that leaders who have
credibility and clout and who make collaboration a high priority will
positively influence the partnership between universities and health
services.
In 2002 nursing leaders from the University and what was then called the
Central Coast and Hunter Area Health Services together mapped out a plan
for improving the quality of clinical education. Most of the issues raised
in The National Review of Nursing Education (Heath et al., 2002) about the
quality of clinical education were also expressed at these local level
meetings and we quickly realised that academics and clinicians shared many
of the same concerns. In 2004 when the Department of Education, Science
and Training (DEST) provided extra funding for clinical initiatives we used
it in part to fund the appointment of Clinical Liaison Nurses and for other
projects of strategic importance.

Data collection methods

The quality assurance project described in this paper was coordinated by
the Director of Clinical Education and undertaken by the Clinical Liaison
Nurses who were each allocated to one of the Health Services. Data were
collected through group interviews, surveys and personal interviews. Over
500 nurses expressed their opinions either orally or in writing. Notes
were made of each meeting and a tally was made of the frequently recurring
issues or problems. Additionally, any recommendations made by clinicians
were also recorded. Recurring themes began to be identified early in the
data collection process and where a solution was obvious and feasible it
was implemented immediately. Once data collection was complete a series of
meetings of the four authors of this paper began as a way of planning the
cross-sectional analysis. This involved a comparison of the outcomes and an
integration of the recurring themes into broader concepts. Data from each
of the health services was strikingly similar, and the amalgamated data are
presented below.

Findings, recommendations and changes to practice

In this section we present a snapshot of the problems and concerns
identified, from the perspective of clinicians and nurse managers, and
their recommendations for improving the quality of clinical learning. While
some of the problems identified had obvious solutions; others were more
complex, and long standing. The changes that were implemented in response
to the recommendations are also discussed here.

1. Communication breakdown between the university and clinicians

Four sub-themes relate to the theme of communication breakdown. These
include scope of practice, difficulty in contacting university staff, lack
of timely information regarding student's placement details, and feedback
systems between the university and clinical venues. Each issue will be
addressed separately.
(a) Scope of practice
One of the concerns frequently expressed by clinicians was that they were
unclear of what students had learnt on campus and in previous clinical
placements. Additionally they were unsure about what clinical activities
students were permitted or should be encouraged to engage in during
clinical placements. Clinicians described instances when students had
attempted procedural skills beyond their level of ability or alternatively
were reluctant to engage in clinical experiences outside of their 'comfort
zone'. Clinicians described their need for a clear outline of the student's
scope of practice specific to each year of the program so that they could
both support and challenge students based upon a clear understanding of the
university expectations. They felt that this information, written in 'plain
English', should be provided by the university for all students undertaking
a clinical placement so that learning opportunities could be maximised.
Changes to Practice
To address clinician's concerns regarding the lack of clear guidelines
specifying what clinical activities students were to engage in during
clinical placements, clear scope of practice documents for each year of the
program were developed (see Scope of Practice). Each one page document was
written in a language that was clearly understood by both students and
clinicians. They were laminated for durability and provided to each unit in
clinical venues utilised by the University. In addition, an online resource
manual that incorporated information about the student's scope of practice
was provided on the School's web site and on the web sites of the Area
Health Departments.

(b) Difficulty in contacting university staff
Clinicians expressed their frustration at not knowing who or how to contact
university academic staff. They acknowledged that while contact details may
have been provided by the University, they was not always available to the
people who needed them most, the Registered Nurses mentoring students. This
meant that when problems occurred as they inevitably do, they were at a
loss as to who to contact. Clinicians cited experiences when they had
mentored challenging students and needed guidance, support and
opportunities to debrief. They expressed frustration, disillusionment and
at times resentment when this type of support was not accessible. While the
clinicians were invariably positive about the importance of the clinical
experience and wanted to provide quality learning opportunities they felt
that they were hindered in their role by not being able to access
appropriate academic staff when needed. Clinicians wanted contact details
of academic staff to be readily available to mentors and the assurance that
their requests for support would be addressed in a timely manner.
Changes to Practice
To ensure that all clinicians had access to academic staff contact details
bright turquoise A3 cards were produced. These cards were provided to
clinicians by each student or clinical educator and posted on the notice
boards in each unit. The cards included the following information:
The student's name and the date of their placement;
The clinical educator's name and page number (if a facilitated
placement); and
The Course Coordinator's name, phone number and e-mail address.
In addition letters were sent as e-mail attachments prior to each clinical
placement by the Director of Clinical Education to the designated contact
person in each venue and/or unit. Letters included the following
information:
The Course Coordinator's name and contact details;
The Director of Clinical Education's contact details;
The student's rostering requirements; and
The student's assessment requirements.
A copy of this letter is also provided to students so that if their mentor
has not received a copy from the designated person the stuent is able to
provide it.

(c) The dissemination of timely information related to clinical placements
Clinicians acknowledged the difficulties inherent in organising and
communicating the placement details for over a thousand students.
Nevertheless they were annoyed when students presented to their units
without them being notified, as happened on occasion. They were also
frustrated when placement details altered and they were not notified.
Nursing Unit Managers in particular wanted these placement details in a
timely manner so that they could ensure that a mentor was rostered to
support the student in practice.
Changes to Practice
The university remains cognisant of the problems described above and has
mechanisms in place aimed at preventing these occurrences. Nevertheless,
communication systems do breakdown at times and the necessary information
regarding students' placements can 'fall through the cracks'. While the
staff working in the clinical unit at the University remain committed to
providing accurate and timely information to venues it remains a challenge.
When names and contact details of designated clinical staff alter, or when
they are on leave, systems can breakdown and it is at these times patience
and understanding between the university and clinical staff is so
important.

(d) Feedback systems between clinical and academic staff
Clinicians believed that feedback mechanisms are vital both to the ongoing
improvement of student's clinical placement experience and to the strength
of the partnership between the university and venues. They believed that
this feedback should be both formal and opportunistic and that both
partners should be comfortable in providing and responsive to the receipt
of such feedback. Perhaps even more importantly clinicians emphasised that
this type of feedback should be fed back to the appropriate people in a
timely manner and be used to promote ongoing discussion and debate, with a
view to improvement of the clinical placement experience for all
stakeholders.
Changes to Practice
In order to improve feedback processes two online questionnaires were
developed in 2004. The first provides a way for students to provide
anonymous quantitative and qualitative feedback to the university regarding
their clinical placement experience. This questionnaire is a 36 item self-
report instrument of which 17 items relate directly to the clinical
environment and the remainder to the students' facilitator or mentor. The
responses are scored on a 4 point Likert scale ranging from strongly agree
to strongly disagree. The second questionnaire provides a way for
clinicians to evaluate the clinical placement experience from their
perspective. It is also completed online and uses the same Likert scale.
There are 12 quantitative items and one qualitative item.
Both questionnaires were implemented at the beginning of 2005. The response
rate from the students has been very high however the response rate from
clinicians to date has been minimal. The results from both will be collated
at the end of each semester and disseminated to the relevant academic and
clinical staff.

2. The role of the mentor

Clinicians described the difficulties involved in providing consistent and
experienced mentors for large numbers of students in light in the
casualisation of the nursing workforce and the number of part time staff
employed. Some clinicians were reluctant to become mentors because of the
escalating demands associated with increased patient acuity and short
staffing. Even so, at times, they took on the role begrudgingly because
'there was no one else to do it'. Mentors reported finding their role
particularly challenging when students needed a great deal of extra time
because of inadequate clinical skills, or when they lacked motivation or
had a poor work ethic. Those that mentored students were especially
concerned about the lack of training they received and their poor
understanding of the universities' expectations. It appeared from the
feedback from mentors that many had little if any preparation for their
role. While many Registered Nurses were willing to adopt the extra
responsibilities inherent in mentoring they wanted training, support and
acknowledgement.
Changes to Practice

The problems described above are not unique or new. A great deal of the
nursing literature has focused on the same issues. And while it seems that
questions and concerns are easy to identify the solutions are far less
obvious. The health care context has become increasingly complex over the
last twenty years. High patient throughput, increased acuity, and decreased
length of stay coupled with current nursing shortages have made nurses'
working lives challenging, intense and often stressful. Despite these
factors it became evident during the meetings held with clinicians that
many still valued the opportunity to mentor students and embraced their
role with commitment and enthusiasm.

In order to improve the preparation of mentors for their role it was
essential that they received adequate training. Although educationally
sound mentor programs had been developed and implemented it was obvious
that we needed to provide increased opportunities for Registered Nurses to
attend. The provision of a DEST funding grant provided backfill for one
hundred Registered Nurses from private and public institutions to attend
the mentor workshops during 2004. These workshops were designed and
implemented collaboratively by the Educators from the Hunter and Central
Coast Area Health Services, the Director of Clinical Education and the
newly appointed Clinical Liaison Nurses. Feedback from each workshop was
consistently positive and they continue to be held regularly.


3. Concerns regarding student's level of clinical competence

Some clinicians were critical of students' apparent lack of clinical
competence, citing examples of third year students who could not prime
intravenous lines or administer oral medications correctly. In many cases
competence was viewed from a narrow perspective as the ability to perform
certain clinical psychomotor skills correctly. Clinicians believed that
there should be certain skills that every student is required to master
prior to graduation and wanted to have input into deciding the types of
skills that were most relevant to the contemporary practice of beginning
nurses. Clinicians felt that the Bachelor of Nursing program overlooked and
failed to consolidate basic nursing skills such as personal hygiene and
assessment of vital signs in favour of more complex skills. Because of this
lack of emphasis on basic skills clinicians suggested that some students
tended to focus on the more 'exciting and technological skills' without
developing competence across a range of areas. In addition clinicians
wanted reassurance that the following areas were addressed adequately in
the program:
Communication skills
Occupational health and safety
Legal issues including The Poisons Act and documentation
Medication administration
Changes to Practice
The recommendations outlined above were timely in that a new curriculum was
being developed for implementation in 2005 and this included the
introduction of a new clinical learning model. A range of initiatives were
introduced in line with our goals of (a) developing and assessing practice
and (b) reassuring the profession that the nurses prepared for practice at
the University of Newcastle meet the ANC National Competency Standards for
the Registered Nurse (2002). The new clinical learning model emphasises
assessment of total performance, including knowledge, skills, values and
attitudes.

While clinical skills are only one aspect of competence they are
nevertheless considered essential. We wanted to be sure that the skills
being taught in the Bachelor of Nursing program were relevant to
contemporary practice so with this in mind we surveyed over five hundred
clinicians to develop a set of 'core skills' considered essential to the
graduate nurse (see table1). Although core skills, along with a range of
other skills, are practiced in the safety of a simulated clinical skills
laboratory students are not considered to have achieved 'mastery' until
they can demonstrate competence across a range of clinical contexts.


4. Concerns regarding assessment of student's readiness for practice

Clinicians described their concern at university processes that allow some
students to graduate when they could not demonstrate the requisite level of
competence expected. They also felt that at times their feedback regarding
unsafe students was dismissed by the university and students were allowed
to progress through the program regardless. Clinicians were prepared to
share the responsibility for clinical teaching but wanted assurance that
their professional judgment would be taken into account when assessing
students.
Changes to Practice
Reports from the National Review of Nursing Education (Heath et al., 2002)
and concerns expressed by nursing regulatory authorities mirror the
concerns about competency attainment described above. In order to address
these professional concerns an innovative clinical assessment process has
recently been implemented into the Bachelor of Nursing program to assess
final semester students. This process, called a Structured Observation and
Assessment of Practice (SOAP), involves a period of observation in a
clinical context by specially trained assessors. Throughout the observation
discrete nursing behaviours are documented using a simple SAO (situation,
action, outcome) format. The assessor then questions the student about the
rationales underpinning particular behaviours to identify knowledge,
attitudes and values, and maps the student's behaviours against the
National Competency Standards (ANC National Competency Standards for the
Registered Nurse, 2002).This technique allows assessors to document the
findings that support their professional judgment in a clear and explicit
manner. It removes ambivalence and provides evidence for assessors to
discriminate areas of performance and make a valid and reliable judgment of
competence. This rigorous process clearly identifies areas of clinical
strength and areas requiring development, and provides students with
structured strategies for improvement. Students are required to
demonstrate competency in order to pass the course and subsequently
graduate.
Over two hundred students have been assessed using this method to date.
There has been a strong correlation between the results of this assessment,
appraisals completed by clinical mentors, and student's previous clinical
results. Students and clinicians have expressed confidence in the
assessment process, valuing the clearly documented evidence of their
clinical competency.

5. Concerns regarding student's lack of preparation for clinical placement

Three sub-themes relate to the theme of preparation for clinical placement:
These include the need for:
(a) Information about venues to be provided to students prior to the their
clinical placement;
(b) Relevant and clear clinical objectives to guide learning; and
(c) Orientation of students to clinical venues.

(a) The need for information about venues to be provided to students prior
to the their clinical placement
Clinicians described the poor preparation of some students for their
clinical placement giving examples of students turning up to 'ward G3',
with no knowledge that it was a 'urology ward'. Clinicians expected
students to be interested enough to familiarise themselves with the
learning opportunities available prior to commencing the clinical
placement.
Changes to Practice
In order to address the problem of poor preparation a 'Clinical Venue
Website' has been developed. Students are able to access information about
the venue including general client profiles, learning opportunities
available, public transport, parking, maps, and other relevant information.
Information for the web site was provided by clinicians and although still
only in the early stages of development it is proving effective.

(b) The need for relevant and clear clinical objectives to guide learning
Clinicians wanted student's learning experiences to be guided by a clear
set of 'plain English' clinical objectives that were realistic and
achievable.
Changes to Practice
Students' learning on clinical placements is now guided by a set of course
objectives listed under the headings of documentation, assessment,
teamwork, communication, procedural skills and law and ethics. In addition
students are required to develop their own set of objectives specific to
each placement. These are based on the course objectives but are specific
to students' individual progress and development needs. Students are
required to develop their objectives prior to commencing the placement,
taking into account the information provided on the "Clinical Venue
Website' and their perceived development needs. On commencement of the
placement students discuss their objectives with their mentor to make sure
that they are realistic and achievable. This has proven effective as it
provides a way for students to articulate their learning needs and also
enhances communication and provides guidance to clinical staff.

(c) Orientation of students to clinical venues
Concerns were expressed that students were not adequately orientated to
clinical areas. Although it was acknowledged that a formal orientation
would be too time consuming clinicians wanted to know that students at
least knew where fire exits and safety equipment was stored.
Changes to Practice
As it was not considered feasible for students to undertake a complete
orientation to each new clinical venue an orientation checklist was
developed that students are required to complete on the first day of each
placement (see orientation checklist).The checklist is signed by the
student's mentor and submitted as part of a clinical portfolio.


Conclusion










References

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http://www.autc.gov.au/projects/completed/clinical_env.pdf
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On clinical placement students can perform skills learnt in their
current semester and prior semesters, under the supervision of their
mentor.
If there are any queries or problems please contact the Student's
Course Coordinator or Clinical Educator
Remember the RN is responsible for the patient and the activity in
which the student engages at all times.

CLINICAL VENUE ORIENTATION

OBJECTIVES

To assist the student to:
Become acquainted with the physical environment of the clinical venue
Gain an understanding of the roles and responsibilities of the staff
within their department
Develop an understanding of hospital policies, procedures, and
resources.

The following are to be completed and signed by the student, and
countersigned by the Facilitator or Clinical Mentor on completion:



I have introduced myself to the Nursing Unit Manager:
_______________________



I am aware of the location of:

Emergency Exits
________________________

Fire extinguishers, hoses and blankets
________________________

Emergency Procedures Manual
________________________

Cardiac arrest bells in patient's room and Nurses Station
________________________

Emergency phone numbers
________________________

Duress alarms
________________________

Staff facilities (including toilets, lockers, staff room, parking and
cafeteria) ________________________



I am familiar with:

The roles of staff within my area
________________________

The Resuscitation Trolley and its contents
________________________

Sharps, clinical and general waste disposal
________________________

Ward layout ________________________



I am able to locate:

Risk Management and Critical Incident Forms
_________________________

The Infection Control Manual
_________________________

Manual handling equipment
_________________________

Personal protective equipment
_________________________

Nursing Procedure and policy manuals
________________________

MIMS and other drug references
________________________





Clinical Educator or Mentor's Signature:
_________________________











Table 1. Core Skills


"Skill "Year "Semester"
"Responding to emergencies in the clinical "1 "1 "
"setting including basic life support using mouth" " "
"to mask. " " "
"Safe patient moving. "1 "1 "
"Hand washing. "1 "1 "
"Taking, recording and interpreting temperature, "1 "2 "
"pulse, respiration and blood pressure. " " "
"Client hygiene – bed bath, oral care, mouth and "1 "2 "
"eye care. " " "
"Assisting the dependent client to ambulate. "1 "2 "
"Administration of oral medications. "1 "2 "
"Blood glucose monitoring. "2 "1 "
"IV infusion management including infusion pumps,"2 "1 "
"monitoring infusion rates, changing flasks and " " "
"cannula removal. " " "
"Pain assessment. "2 "1 "
"Management of oxygen therapy and oxygen delivery"2 "2 "
"devices. " " "
"Oxygen saturation monitoring. "2 "2 "
"Comprehensive mental health assessment and "2 "2 "
"history taking. " " "
"Aseptic technique. "3 "1 "
"IV medication administration via bolus and "3 "1 "
"burette. " " "








-----------------------


Skills that can be performed on Clinical with Supervision

Management of oxygen therapy and O2 delivery devices.
Oxygen saturation monitoring
Respiratory assessment (Spirometry and peak flow)
Administration of inhalant medication via nebuliser and spacer
Cardiac assessment and continuous cardiac monitoring
12 lead electrocardiogram
Life support using oropharyngeal airway, bag and mask
Neurological assessment (eg Glasgow Coma Scale)
Assessment and management of a stroke client
Assisting the client who has had a stroke with ADLs
Nutrition management for patients with impaired swallowing
Nasogastric suctioning for patients with impaired swallowing.
Assist patients with a mobility deficit (eg. stroke)
Providing a safe environment and assisting the client who has a sensory
impairment
Communicating with clients with expressive or receptive aphasia following
a stroke
Comprehensive mental health assessment and history taking
Assessment of suicide risk
Management of aggressive and/or violent behaviour
Pre and post procedure care – ECT
Motivational interviewing
Principles of supported recovery and rehabilitation in mental health
Administration of medication for clients with mental health problems



1ST SEMESTER
A 2 week aged care and a 2 week med/surg clinical placement.


Skills Learnt in Clinical Skills Labs

2nd SEMESTER
A 2-week mental health and a 2 week med/surg clinical placement.



Skills Learnt in Clinical Skills
Labs


2nd YEAR
Nursing Student


Skills that can be performed on Clinical with Supervision

Pre/post operative care
Pre and post investigative care
Fluid status assessment and documentation
Catheter management
Continence assessment and management
Nutrition assessment
Nasogastric tube insertion , suction and feeding
Stoma assessment and management
Aseptic technique
Assessment and management of surgical wounds including suture and clip
removal
Management and Removal of wound drains
Assessment and management of chronic wounds
Pressure area prevention
Blood glucose monitoring
Client education regarding diabetic foot care
IV infusion management including infusion pumps, monitoring infusion
rates, changing flasks and cannula removal.
Administration of IV medications via a bolus injection and burette
Administration of IM and SC medications
Administration of rectal medications
Pain assessment
Pain management including PCA management