The twin problems that arise repeatedly in providing meaningful clinical experiences for nursing students are (1) the availability of patients on any single nursing unit who demonstrate nursing care problems closely related to current classroom content and (2) the increasing number of students each instructor must help to extract maximum learning from each clinical experience.
It is unlikely that an instructor can plan to assign each of her ten to twelve students to a patient whose major problem is meeting his oxygen needs or who has some malfunction of the gastrointestinal tract or frank rehabilitative needs. Yet such patient assignments are necessary if classroom and clinical experiences are to be concurrent and correlated. In addition, having to know the history, medical problems, preferences, nursing problems, and prognoses for ten to twelve patients requires a great deal of an instructor. Such knowledge is necessary, however, if the instructor is to guide and motivate her students to give thoughtful, knowledgeable care to each patient.
One of the newer methods of assignment- group or multiple student assignment-decreases the number of "suitable" patients necessary for meaningful clinical experiences and provides for several additional beneficial student learning experiences.* In this method of assignment two, three, four, or perhaps more students are delegated to care for a single patient It is obvious that this approach decreases the number of appropriate patients needed to provide meaningful experiences for any one clinical laboratory. The instructor is much more likely to find three, four, or six appropriate patients on a given nursing unit and is more likely to acquire depth in her knowledge of these few patients.
Assigning students in pairs is most appropriate for first-year students, who need and desire practice in beginning nursing techniques such as bedmaking and bathing a patient As students advance they can perhaps benefit more from being assigned in groups of three or four; one or two might give more complex daily patient care; one or two give newer treatments, medications, and gather information about the patient and his illness; and one observe the patient's nursing care. Varying the number in the group in this manner allows each beginning student a clinical laboratory period of practice in basic patient care This is alternated with a laboratory period of delving into the patient's record, using reference books to understand specific details of the patient's illness and treatment, interacting with the patient, observing his care, and perhaps practicing a skill (TPR; B/P; giving medication). These skills must be mastered separately before they are integrated into the basic patient care that students at a particular stage of education are able to give. When a student progresses to the point where additional practice in basic nursing techniques is less meaningful, assignment to a larger group is advisable. The larger group allows for fewer clinical laboratory periods of practice of the already familiar basic nursing skills and provides time for more detailed understanding of the patient's medical and nursing problems as well as for the practice of more complex techniques and clinical laboratory observation.
The importance of the observer role should not be overlooked. From her brief periods of observation, a beginning nursing student increases her familiarity with basic technical skills. In addition, her observation of the nurse-patient relationship helps her to gain insight into her own behavior with patients. With longer, formal periods of observation the more advanced student can be guided toward seeing an overall picture of patient care, providing her with several bases for comparison, which may help her in evaluating the nursing care she gives to patients and may increase her ability to analyze patient care.
The observer makes a major contribution to the nursing student who is giving direct patient care. She is a person with whom the doer can validate her experiences with the patient. She also is in an excellent position to discover better ways of caring for a particular patient and to offer constructive criticism.
The use of clinical laboratory time for the student to gather information on the patient's illness and course of treatment catches the student at a period of peak interest in understanding what has happened to this patient. In addition, by using reference books to meet her immediate (during clinical practice) needs for knowledge about a patient she will, hopefully, be establishing a pattern which will persist after graduation.
Isolating the newer skills that a student must become familiar with and allowing her ample time and freedom from other responsibilities gives a student the opportunity to discover why this skill or treatment is part of a particular patient's care. She also has time to understand the principles underlying this new skill, to familiarize herself with the equipment and sequence of events used in performing the skill, to give care to the patient without feeling rushed, and to evaluate her ability and performance. In short, she is given an opportunity to use problem solving techniques.
The experience of working closely with other students necessitates a certain amount of communication and cooperation. As the size of the group increases, so does the complexity of the working relationship among the nursing students in a particular group. When the popularity of the team movement in nursing, with its inherent need for cooperation among the team members, is considered one realizes that helping students to set guidelines for effective patterns of team interaction early in their nursing education is especially important.
The instructor generally is the person who chooses which of her students will work together. She frequently will allow students to decide which role they will fill in caring for their patient, stipulating only that in subsequent clinical laboratory periods the students in each group must change roles until each one has had experience in filling all the roles. The group then is dissolved. It is, of course, advisable that the group continue to care for the same patient until this sequence is completed.
In her choice of group members the instructor can set the stage for the students' working relationships, which may vary from relaxed to stressful. Her choice of the type of relationship she wishes the students to encounter is determined by what group experiences, with guidance, she thinks will produce optimum growth among the students.
Permitting students to choose their own roles involves them more directly in their learning process and gives them some opportunity to work out their own personal solutions for handling new, frightening, or less interesting situations. Within this framework, the student who is apprehensive about the appropriate techniques for irrigating a catheter, for example, has freedom within her group to volunteer for the treatment role, being the first in the group to do the catheter irrigation and, thus "get it over with," or to volunteer for one of the other roles and observe her classmates in the procedure before she has to do it herself.
The major disadvantage of the group or multiple method of clinical assignment is that a particular patient's care seems to be segmented. One fears that the nursing student will never see the patient as a whole. In working with this method of assignment this writer has found that the patient gains a semblance of wholeness as a result of group planning of his care in preclinical conference, group sharing of details of individual experiences in postconference, and each student's experiences with the patient as dictated by the various roles she takes within the group.
By guiding the students to consider the whole patient, the instructor can minimize the major disadvantage of somewhat segmented patient care to the point where the additional advantages far outweigh this disadvantage. It would seem that this method of nursing student assignment helps in providing meaningful experiences in the clinical laboratory and makes it possible for the instructor to stimulate the student to nearly maximum learning.