The transition from baccalaureate nursing student to staff nurse remains a highly significant problem for both nursing education and nursing service. Preparing the student to assume the role of beginning practitioner requires a concentration of effort by faculty. This challenge to nursing education has received considerable attention during the last decade, partly because of the work of Kramer and Schmalenberg (1970, 1974, 1976, 1977), Benner and Benner (1975), Huckabay (1979) and others. The collective emphasis in their work is upon the promotion of satisfactory role adjustment for the new graduate. While anticipatory professional socialization is recognized as a process to be undertaken, there remains the need for faculty to modify their teaching approaches in order to assist students who are completing their educational program.
This paper proposes to explore clinical teaching and its importance in helping Senior students to master role transition. Specific teaching strategies which facilitate learning of Senior students can promote role adjustment and minimize stress for the student. The authors emphasize the critical importance of the faculty member in the development of the Senior student. The faculty member assumes responsibility to both nursing education and nursing service for the graduate of the baccalaureate nursing program. There is no replacement for the knowledge, skill, empathy and motivation of the experienced faculty member in serving as mentor, facilitator, and role model for the Senior student. In addition to the presence of faculty expertise, a practicum appears to be the appropriate format for role learning to take place.
With the aim of assisting Senior nursing students to move more effectively into the role of beginning staff nurses, an eight-week practicum was designed within the Nursing Education Program at The Johns Hopkins University. The objectives of the course were the following:
1. To help the student synthesize knowledge and experience learned in previous courses through multidisciplinary analysis of clinical, human, and organizational forces affecting health care delivery;
2. To clarify and/or plan appropriate responses toward the goal of health promotion of groups of clients;
3. To facilitate the role transition of the student to that of beginning graduate practitioner capable of exercising the responsibility and authority required of a professional nurse accountable to a group of clients and a health care team.
The goal of the Senior Practicum was the successful transition of a Senior student into a role as close as possible to that of a staff nurse. The practicum built on previous course work, and it integrated the major foci of the upper-division nursing program. A perspective on humanistic nursing as a response to needs of clients and their ability for self-care allowed students to develop further their own dynamic concept of nursing. Emphasis in the course was on the refinement of the student's philosophy of nursing as this belief system was incorporated into clinical practice.
Utilizing previous knowledge and skill, students were encouraged to set personal goals for learning within the framework of the course objectives. Students eagerly anticipated the practicum as a final expression of their student learning and as a unique opportunity to meet their own needs as potential graduate practitioners. Time requirements included five hours of class time weekly and three eight-hour clinical days. Students selected an area for clinical practice with children or adults within the acute care setting or in community health areas.
Identification of Teaching Strategies
Imperative to the success of the course was identification of individual and group learner needs - by both the students and the faculty. Student objectives usually related to a desire to function in a role that closely resembled that of a staff nurse. Although the perception of this role certainly included anxiety regarding the performance of technical skills, students' concerns were also directed toward resolving conflict situations which they perceived in the setting. Generally these perceived conflicts involved the student's own view of himself/ herself as a professional person attempting a level of practice in settings which often appeared to reward technical nursing.
These concerns were kept in mind as faculty members selected approaches which would foster independence among the Senior students while providing necessary support. In order to meet the stated objectives, the following teaching strategies were identified and adapted to each clinical unit:
1. The instructor would gradually move from the traditional role, which many times is supervisory in nature, to one in which she would serve as a resource person to confirm and reinforce student behaviors.
2. Student involvement with staff would be increased so that the student could analyze staff organization and relations and view himself /herself as an integral part of the staff.
3. The student would be responsible for gathering patient data on the day of the clinical experience rather than in advance of the experience; the purpose of this would be to move the student into a more realistic time frame for nursing. In addition, the student would be required to utilize available resources on the unit to gather additional information about those areas with which he/she was unfamiliar.
4. The student would be required to deliver care within the prevailing mode of the unit (e.g., team nursing, primary nursing, block nursing) rather than by assignment of the instructor.
5. The student would be responsible for designing nursing care plans for patients as part of his/her ongoing responsibility to patients and staff rather than as an assignment to be completed for faculty.
6. The student would be expected to analyze conflict situations which confronted him/her and to manage these situations using an appropriate rationale.
7. The student would be expected to analyze his/her daily practice in relation to his/her system of values, beliefs, and philosophy of nursing.
Implementation of Teaching Strategies
The choice of clinical sites was the key to the success of the practicum. In preparation for the course, faculty members developed descriptions of learning opportunities within the various clinical settings. Students were then able to choose the setting which would most closely fulfill their own personal objectives in addition to the objectives of the course. Faculty members viewed themselves as facilitators for the student's own independent practice at this time, within the natural constraints of the particular settings. For example, primary care settings provided many opportunities for students to develop their skills in physical and psychosocial assessment as well as in patient teaching. However, the expanded role of the nurse practitioner cannot be duplicated by a student, and so the student in primary care adapted herself to working with the close support of the nurse practitioner. In these situations, students quickly appreciated the variety and range of the nurse's contribution to patient care. The student's ability to articulate the viewpoint of nursing was often called upon within the primary care setting as the student interacted with physicians, nurses, physicians' assistants and nurse practitioners. However, the intensive care units were not developed as clinical sites by the faculty, despite requests from students, because in such units the student would have to be co-assigned patients with the staff nurse to the extent that role adjustment would be inhibited or delayed.
The choice of clinical settings as well as the assignment of patients within the clinical settings must be based upon the prior clinical experiences offered in the program, the facilities available, the capabilities of the student, the capabilities of the faculty, and the acuteness of the units. For example, students on the leukemia service were assigned one or two critically ill patients while students on the medical service were assigned a larger group of patients. In any setting, the student assignment should duplicate those of the staff as closely as possible. The choice of setting will also influence the number of students to be assigned to the unit and the student-faculty ratio. In this practicum, the student-faculty ratio ranged from 1:3 in primary care to 1:6 in the acute medical and oncological settings. Instructors need to be intimately familiar with the clinical site in order to be of maximum assistance to the students in the provision of nursing care and in the examination and understanding of organizational structure and patterns of leadership. For this reason, instructors chose sites where they had instructed during the preceding semester. If this had not been possible, a "working" orientation to the units would have been considered.
The utilization of units which had been used the preceding semester was also helpful in the establishment of relationships with administration and staff. Because students were responsible for an everincreasing number of patients with multiple complex problems, staff trust in the capabilities of the instructor was crucial. In addition, with the student group frequently having responsibility for the care of much of the patient population of the unit, the instructor was of necessity more dependent upon the staff, especially for provision of information concerning student performance.
Orientation of staff on the units, particularly head nurses, was conducted to inform staff about the objectives, classroom content, and preparation of assignments. The changing role of students and instructors was also identified. The staff was informed that as the course progressed instructors would be present on the unit for shorter periods of time. However, the instructor's responsibility would not change, and she would carefully monitor student progress. The aim of the course was not, after all, to have staff function as instructors.
In the orientation of students to the unit, in addition to the usual information concerning unit procedures, the change in the role of the student and instructor was again emphasized. Students would gradually progress, dependent upon individual capabilities, to a position of less dependence on the instructor. Students were encouraged also to depend less on fellow students and instead to seek out staff members when needing assistance. Attempts were also made to provide students with basic information about the organizational structure, character, and history of the assigned unit.
When the course began, students were guided in a manner very similar to that of preceding courses. For example, on several units, patient assignments were "posted" on the day preceding the clinical experience in order that the student would have ample time to prepare. However, after two to three weeks on the floor, students began receiving their assignments on the day of the clinical experience. The time at which this was done was adjusted according to the needs of each individual student. The students who had been on the same unit the preceding semester, as opposed to those who were on the unit for the first time, usually advanced to this point first. The idea of reporting to the clinical unit without having spent a day in preparation was very threatening and anxiety-producing for most students. To alleviate this anxiety, a clinical seminar was conducted by the instructor; students were provided with the methodology for quickly reviewing a chart in order to obtain the information that was vital for immediate care of the patients. Resources for providing answers to clinical questions were also reviewed.
The change in the functioning of the student was also somewhat anxiety-producing for the instructor. Selection of patient assignments was usually made by the instructor the day preceding the clinical experience in order that the instructor would have ample time to prepare for the clinical day. As students progressed, however, this was not always necessary; student assignments could be decided the day of the clinical experience before or during the change-of-shift report. Gradual advancement of students to this level was of assistance to the instructor. In this way some of the students could have their assignments posted the preceding day, allowing preparation in the usual manner, while others of the group could be assisted with the review of charts and organization of care on the day of clinical experience. As students became comfortable with this change, the number and/or complexity of patients assigned on the day shift gradually increased before the same procedure was followed on the evening, night, or weekend shifts. Again, before taking students to another shift, a clinical seminar was conducted to familiarize students with the routines and responsibilities of that particular shift.
As students progressed in their level of competency and as the amount of work they had to complete during the shift also increased, the instructor automatically became less involved with each individual student. However, as verbalized by students in previous years, the knowledge that the instructor was physically present on the unit, even if in the conference room with a student, was a very reassuring feeling; students knew the instructor was available if an emergency or crisis of some sort should arise. For this reason, instructors made specific attempts to be absent from the unit for prescribed lengths of time. The head nurse and the unit clerk were informed as to where the instructor could be contacted and the rationale for the instructor being absent from the floor was reinforced.
Clinical seminars served to integrate clinical experience with material presented in the theory portion of the course in addition to serving as a means of providing students with information relating to specific clinical units. Procedural topics included discussion of the unit's format for admission and discharge of patients with inclusion of the appropriate written work, development of nursing orders, routines associated with evening and night shifts, and the gathering and giving of the end-ofshift report. Opportunities for practice team assignments and for discussing unit leadership patterns and ethical concerns were also provided.
In addition, opportunities for individual conferences were available to students. Purposes of individual conferences varied with student objectives; for example, several students identified pathophysiology as an area of weakness and used conference time to discuss pathophysiology in relation to specific patients. However, regardless of the prestated individual objectives, individual conferences were many times used to discuss future career decisions, interpersonal relations with staff and patients, and considerations of an ethical nature. Many of the items of concern to students were felt to surface because of the extended length of time on the clinical unit and the increased involvement with activities of the unit - an opportunity not previously provided in the nursing curriculum.
One of the problems encountered in the practicum was the intensity of the experience. With the long and varied clinical hours, in addition to the theory hours, students found that in most cases they did not have an opportunity to prepare for clinical days in the way they had for previous courses. In some ways this change was a welcome one, but it was none the less anxietyproducing for the student. Students dealt with the problem by developing alternative methods for datagathering (e.g., other staff nurses and medical and nursing rounds). In this way, students gained information about the patient as well as learned access to the system and about the system.
Students also had to attempt to work within a limited time frame. Few professions demand completion of responsibilities within an eight-hour period as does nursing. Most student clinical experiences do not require this conformance. In many clinical experiences the student either had clinical experience for three or four hours and whatever was not completed by the student was completed by the staff. Development of careplans was usually completed outside of clinical time. The Senior practicum required both patient care and careplans to be completed during an eight-hour day.
The eight-hour day also necessitated the giving of report to the following shift - a new experience for many students. Clinical seminar time as well as individual conference time was devoted to development of reporting skills. Guidance was particularly needed with acute patients on whom there was more to report than merely "stable vital signs." The intensity of the clinical experience also made it possible for students to observe continuity of care or the lack thereof from one shift to the next and to the following day.
The practicum developed for these groups of Senior students was viewed as an immersion type of experience which would help students deal with the realities of the staff nurse role. Graduates of the program moved quickly into staff positions; after one year and two years respectively, all of the members of the classes of 1978 and 1979 were actively involved in nursing practice. Students and faculty believed that the practicum was a satisfactory vehicle for helping students make the difficult transition to the staff situation.
- Benner P. & Benner, R. The New Nurse's Work Entry: A Troubled Sponsorship. New York: Tiresias Press, 1979.
- Huckabay, L. Point of view: Nursing science and education, is there a chasm? Nursing Administration Quarterly, 1979, 3, 51-54.
- Kramer, M. Role conceptions of baccalaureate nurses and success in hospital nursing. Nursing Research, 1970, 19, 428-439.
- Kramer, M. Reality Shock: Why Nurses Leave Nursing. St. Louis: CV. Mosby Co., 1974.
- Kramer, M., & Schmalenberg, C. Conflict: the cutting edge of growth. Journal of Nursing Administration, 1976, 6, 19-25.
- Kramer, M., & Schmalenberg, C. Path to Biculturalism. Wakefield, Maryland: Contemporary Pub. Co., 1977.
- Minehan, P. Nurse role conception. Nursing Research, 1977,26, 374-379.
- Scipien, G. & Pasternak, S.B. Creating more confident baccalaureate graduates. American Journal of Nursing. 1977, 77, 818-820.