The optimum learning experience for the nursing student promotes his or her growth in skills, interpersonal awareness, self-awareness, and knowledge. Cumulatively, such an experience assists the nursing student to integrate more effectively the "real" with the "professional" and the "ivory tower" with the "practical." A recent research study by Brief et al. found evidence that this integration is not occurring.1 Using a sample of 117 registered nurses, it was found that role stress increased with the degree of professional training, baccalaureate nurses experiencing the greatest stress. They suggest that role stress occurs as a direct result of incongruence between the educationally defined role and the role as defined by the employing organization. Nursing education and nursing service must find ways to work together to foster congruence of the nursing role.
The use of the clinical nursing unit as a learning laboratory for nursing students is a purposeful and potentially rich approach to the optimization of the student learning experience. We feel strongly, however, that operations within the clinical nursing unit between and among staff, students, authority figures, and clients must be subject to observation, evaluation, and discussion. Most importantly, we believe that such a process must take place within the matrix of an alliance of the forces operating in the unit if student learning is maximized rather than blocked. This article describes a method ("The Three-Way Conference") of alliance among nursing education, nursing service and the student nurse.
"When all goes well," says the old cliche, "no one notices; but when mistakes are made everybody sees." So it is with nursing students: when they perform well, there is silence; when they err - as they inevitably will - there is loud criticism. Authors such as Watson point out the need for educators to be more supportive of students' selfdirective learning needs.2 When encouraged in this direction, says Watson, students gain richness in their own lives, but they are also more likely to stumble along and make mistakes. Others suggest the value of collaborative alliances between service and education,3*4 to create a positive climate for self-directed learning, and Nichols describes a method for staff participation with students doing clinical experience in which staff nurses complete a written evaluation for each student. She warns, however that at times there is discrepancy in the feedback: the staff nurses give positive verbal feedback to the student and negative written feedback to the educator. This plan not only has limited value for the student, but it can breed problems, like any two-way communication involving three people.
One variant of the traditional two-way model (educator to student, student to supervisor and supervisor to educator) goes as follows. Nursing service notices unsatisfactory student behavior, thinks "\ sure can't let her out to practice on people," and acts by informing the educator that "Jane is a terrible student, don't let her do anything unless you're right there to watch her." This approach produces a real dilemma for the educator.
In a second variant, nursing service notices unsatisfactory performance, thinks the school is at fault, and acts by telling other service people about the poor student's inadequate preparation, or by supporting the student in the view that her school is awful and her salvation lies in letting service people "show her the ropes." This approach produces a real dilemma for the supervisor.
Both of these alternatives demonstrate triangles,5 which leave at least one person a loser and may start an interagency war. More importantly, the student is left with diminished support, uncertain feelings about nursing service people or nurse educators, and decreased potential for surviving entry ("role socialization") into the scary world of nursing service.
The Tavistock studies point out that splitting between education and service systems promotes splitting in the student's cognitive and emotional integration, which in turn may produce discouragement, low morale, academic failure and rising attrition. Anxiety generated by the "splitting" experience is attributed by the student to "the system" of either the school of nursing or the clinical unit, and thus the potential use of energy in the service of learning is lost.6 When the representatives of the two systems - the nurse educator and nurse supervisor - are allied meaningfully with the student, the available energy can be redirected meaningfully towards adaptive integration by the student.
The three-way conference is a method developed by the authors for renewing the neglected alliance between nursing education and nursing service and correcting the problems inherent in diadic communication about triadic concerns. Doona and Kantrowich also recognized the need for a service-education alliance though they utilized a group process method, holding large conferences for the entire student group.7 In the three-way conference, nursing student, nursing educator, and nursing supervisor discuss together the students' professional development and her impact on a health care system, in order to identify strengths as well as problems and to facilitate problem-solving. The authors originated the three-way conference to confront conflict directly, and to help students integrate theory and practice. They have held the conferences for three years, and have worked with approximately 60 senior nursing students doing clinical work on a psychiatric inpatient unit of a large teaching hospital. The students spend 12 hours a week for one semester in this clinical area. The nursing supervisor is an employee of the hospital and responsible for nursing care as well as collaborative and coordinative liaison with various teaching programs. The nursing educator is based in the School of Nursing and functions as a member of the interdisciplinary team as well as supervisor for the students' clinical work.
The three-way conferences usually take place three to four weeks into the semester, again at ten weeks, and finally as students terminate the clinical experience. No specific agenda is planned. The conferences last 15-30 minutes for each student, so time involvement is minimal-much less than for the group process method described by Doona and Kantrowich.
Near the beginning of the student experience, the supervisor and educator briefly define the three-way conference - to provide an opportunity for the student to initiate evaluative exchange. The student is informed of the availability of conferences and told that they will constitute the only basis the nursing educator and nursing supervisor will use for exchange about the individual student, i.e., "We will not discuss you unless you are present." This also sets the expectation that the student will not complain about nursing service to the educator and vice versa. The conferences are optional; however, both the educator and supervisor support them as worthwhile experiences and more than ninety percent of students elect them.
The approach-avoidance conflict in nursing students is particularly obvious prior to the first conference, which students frequently perceive as an unfamiliar and scary situation. In the approximately ten percent who choose not to participate, the authors have observed marked mistrust of authority figures combined with high levels of interpersonal guarding or narrow learning goals. This tends to confirm the view of Nichols and Heydman, who suggest that the student who is an inconsistent performer or who is uninvolved in the clinical setting because of other priori ties is most apt to decline input from nursing service.
One student who was very nervous about the three-way conference postponed the initial meeting at least three times. When the conference finally began she talked in her usual "chit-chatty" manner, smiling, making superficial comments about experiences and her individual patient. The educator had been trying to deal unsuccessfully with this same behavior - Cathy's facade - in earlier contacts. On this day, the supervisor finally interrupted and asked what she was so nervous about. Cathy hesitated and then related her fears that the supervisor and educator would "analyze" her and figure out that she was crazy. She also confided that she felt very inadequate and therefore had to convey a "facade of confidence." The supervisor suggested that this was reflected in her nursing notes, which presented the patient as "fine," though other staff members felt quite concerned about the patient's denial and depth of depression. The three-way conference did not resolve this student's difficulties, they were too great, but at least it provided her with a safe experience to begin confronting her need for interpersonal guarding.
A restatement of purpose is offered at the time of the first conference. The student usually speaks first, and is encouraged to initiate the process of evaluation, review, and feedback. At first, the student typically speaks superficially and in positive terms about the experience. The educator and supervisor offer supportive remarks which encourage clearer definition of the areas for growth to which the student has alluded. It is of great importance that in the first conference the student be given permission and power to explore her own needs and potential for change. Impulses on the part of the educator or supervisor to point out in a definitive way the student's problematic interpersonal areas must be restrained in the interest of maintaining a climate of support and developing trust. Encouraging early (rather than late) identification of growth needs and verbalizing the alliance felt by educator and supervisor with the student are two strategies used in the conferences. Students are told, "Let us know what you want to learn about yourself and the sooner the better." In a few instances the student fails to take the initiative to discuss growth areas. In such cases, the educator or supervisor may overtly provide a focus for discussion through such comments as, "What would you like to work on during this experience?" or "What is your thought about an area I have observed. . .?"
In dealing with the anxiety of the learning experience for the student, the educator and supervisor jointly support the formulation of a plan of action, provide both positive and negative feedback, and express an attitude of positive regard for the student. They seek to keep the weight of the conference on those things the student does well; ruminating about problems is carefully avoided.
When the alliance students are encouraged to feel with educator and supervisor is temporarily lost, the impact can be considerable. On a morning when Susan perceived herself to have been turned down by both educator and supervisor on separate issues, she was asked for a favor by her patient. Feeling herself abandoned, she promptly turned the patient down and, as a result, he missed two weeks of interviews. After the educator and supervisor tuned back in and let the student know she was cared about, Susan was able to go in and talk honestly with the patient about what had happened between them. The threeway conferences provided an opportunity to put together the dynamics of the student-authority and student-client interaction. More importantly, the discussion helped the student to identify an "all or nothing" value she attached to relationships. One refusal was perceived as total rejection. Since the student and patient were dealing with the same issue, when the student could deal with her own fear she was enabled to help the patient deal with his fear of rejection.
As the student begins to perceive similarities between herself (and friends/family) and clients, her introspection increases. Carol's attitude about psychiatric nursing was initially a real hindrance to her; she saw therapy as not useful and possibly harmful, and she had rejected it for herself at an earlier point in her educational adjustment. Her interviewing skills were so bad her patient avoided the interviews. Earlier in her clinical experience, she had set up adversarial confrontations with both educator and supervisor. Three-way conferences proved a useful method to promote discussion of what was transpiring. Carol was able to see, through the multiplication of examples, a pattern in which she set up control and attack by authority figures. For the first time she began to consider the points being made repeatedly in her clinical supervisory sessions (educator-student). As three-way conferences proceeded, Carol began to trace her discomfort with her patient, an. aggressive male with impulse control problems. She realized that her fear of him (and other men, including the male supervisor) was a transference of the fear she had experienced as a small child when her father yelled at her and slapped her. Her conscious recognition of her reaction to aggression and closeness, facilitated by the three-way conferences, led to introspection and behavioral changes which were continuous after her clinical experience in this setting ended.
It should be noted here that the phase of the three-way conferences tend to parallel the phases of a therapy relationship: during orientation, trust is a major variable and during the working phase more confrontation can be helpfully utilized. In both these phases it is critical that the student (like the client) retains control over her own learning. Such control is most likely to occur when the student sets the pace for the conference and the authority figures maintain their commitment not to discuss her in her absence. During termination, appreciations, regrets and resentments are discussed, but there is no further exploration of new issues.
The three-way conference method can also assist the supervisor and educator in looking at issues. For instance, Sally - a verbally aggressive student - brought up in conference her perception of a problem with the therapeutic milieu, i.e., oftentimes the nurses didn't participate in team conferences. Her perception was valid, and realizing it, both educator and supervisor worked to develop a plan for change in the milieu. In this instance the student's fresher awareness brought renewed awareness in educator and supervisor of an area that had become a "blind-spot." Of secondary but still useful importance: Sally got an opportunity to consider the impact of "aggressive" versus "assertive" behavior. During earlier student-educator conferences, the educator's observation that the student was aggressive had elicited a response of "You're not comfortable with assertive students." During the three-way conference, the nurse supervisor responded to the student with, "I think you're right about the milieu but something about the way you're saying it makes it hard for me to hear you." This feedback helped the student to think more seriously about how to get her messages heard.
Doris provides another example of the kind of work accomplished in three-way conferences. Doris struggled with rescue fantasies and entered the relationship with her patient with much energy to "cure" him. When he didn't respond immediately to her helpfulness, she became overwhelmed, felt helpless, and withdrew. "I can do it all" became "I can do nothing." In a conference with the educator, the student acknowledged that she was reluctant to become involved because of a traumatic breakup with a boyfriend and the impending death of a beloved grandmother. She saw her own grief work as a priority. When the second three-way conference took place, the supervisor observed that the student seemed uninvolved, but distressed; he wondered if she was dealing with a personal crisis. The student glanced at the instructor as if to get permission to confide in this other person. Then she worked to identify the nature of her detachment and to sort out the possible interpretations of her behavior: uncaring, pretty but dumb, withdrawn, or incapable (as her behavior might be perceived by others, including her patient). She identified two outcomes for the three-way conference process: (1) it's all right to share with authority figures how one feels; in fact, one may be both understood and supported; (2) it's useful to set limits on what therapist and patient will deal with in therapy sessions. When later she said to the patient, "I can't deal with your grief today because I'm worried about a sick family member," the patient saw her as real, concerned, and invested in their relationship. He responded: "Oh, I'm sorry I thought you iust weren't interested in my problems."
In addition to resolving conflict in the students' clinical experiences, the threeway conferences heighten students' feelings of security. In perceiving the two authority figures in their immediate space as respectfully allied, and in perceiving the climate of the unit as one in which people are treated as adults, the educational program is valued and concerns are handled openly; students perceive their own vulnerability, feelings, reactions, strengths and weaknesses in a different light. The result for the student is greater openness, more hopefulness, and more definite problem-solving. It has frequently been observed that a student is more motivated to examine her behavior and accept responsibility for its impact on others if two people simultaneously confront her with different examples of her interactional pattern. In one-to-one conferences - as many faculty have seen - it is all too easy for the student to say (or at ieast to think): "That's your opinion! Who cares?" The multiplication of examples in the climate of alliance and support promotes introspection.
Though the success of the three-way conferences is partially due to the longstanding respectful relationship of the authors-nursing supervisor and educator it is entirely feasible for others to implement this model. Experience and understanding of human behavior increase the effectiveness of the model in dealing with the multiplicity of student issues. Especially in busy or high stress areas, the educator and supervisor must plan a time to meet with the students; impromptu feedback alone tends to be much less reliable or facilitative. Avoiding triangles and taking risks during three-way conferences are important elements, supporting successful use of the model. Three-way conferences provide the setting for a crucial task in which nursing service and nursing education are inevitably allied: the conjunction in the student of the real world with the theory world. Though the conferences were originated in a psychiatric inpatient unit, they can be replicated in any clinical setting. In every setting, students confront the task of bringing together within themselves the meanings of varied experiences. In three-way conferences, a student may be helped to recognize that problems she identified have relevance to her roles both as student and practitioner, and that "her problems" will not be solved by graduating. The student begins to take responsibility for her impact on others and to practice more interdependent behavior in professional relationships.
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