While clinical experience is generally viewed as an integral component of education essential to the preparation of a qualified nurse, there is little reported research examining the contribution of this component (Infante, 1975; Pugh, 1983). Historically, clinical experiences were not developed in response to identified competencies that must be possessed by the graduate. Instead, the priority given to these experiences in nursing education has been rooted in tradition only. In Nightingale's day, apprenticeship was an accepted avenue into all professions and her plan for educating nurses followed this tradition of clinical experience (Ashley, 1976). The clinical experiences of nursing students have centered largely on caring for patients. Experience has been a goal in itself with "knowledge supposedly absorbed by contact" (Zasowska, 1967, p. 51) rather than a means to learn.
There is general agreement that because of the time and expense involved in providing the clinical component of nursing education, this specific experience should be used only if the learning outcomes could not be achieved utilizing other learning experiences (Infante, 1981; Ragsdale, 1980; Zungolo, 1972). Probably no academic major in a higher education setting requires more credit hours of clinical experience than those required of nursing students (Dienemann, 1983; Lazinski, 1979). Yet the history of nursing education and the lack of research related to the exact learning that occurs during clinical experience suggest that these practices are continued only on some vague assumption that they are effective (Zungolo, 1972). Learning from experience begs the question, "Learning what?" (Zasowska, 1967, p. 21). Indeed, previous researchers have cited the need for identification of the learning that occurs during clinical experience (Ragsdale, 1980; Zungolo, 1972).
This exploratory study examines two potential learning outcomes of clinical experience: the ability to make sound clinical judgments and the development of professional identity. A major goal in the education of nurses is and always has been to enable students to make sound clinical judgments (Jenkins, 1985). Benner (1984) adapted a model of skill acquisition (Dreyfus & Dreyfus, 1980) to the practice of nursing and proposed five levels of proficiency: novice, advanced beginner, competent, proficient, and expert. Experience is a requisite for expertise.
Experience, as used by Benner (1983), resulted when preconceived notions and expectations were challenged, refined, or not confirmed by the actual situation: "It is the particular interaction with the learner's prior knowledge that creates the 'experience,' that is, the particular refinement or turning around of preconceptions and prior understanding" (p. 40). Thus, both background knowledge and experience are required. Benner has provided a framework for hypothesizing that clinical experience contributes to clinical judgment as the individual moves "from reliance on abstract principles to the use of past, concrete experience as paradigm" (1982, p. 402).
Utilizing Benner's framework to build her argument, del Bueno (1983) found that nurses with at least 7 months of experience after graduation made fewer decision errors than nurses who had less than 7 months' experience. Similarly, the writings of Benner suggest that differing amounts of clinical experience by the student at the novice level could be detected by examining the accuracy of clinical judgments.
This study also explores the development of professional identity as a potential learning outcome of clinical experience. The psychological development of students into functioning professional nurses influences the kind of care that they will provide to clients (Burgess, 1980; Gunter, 1969). Chickering (1969) specified the dimensions of development that occur during the college years and provided a definition for the development of identity. Chickering noted that environmental conditions can foster or inhibit developmental change. Clinical experience might foster a student's development of professional identity, and Christian (1974) has adapted the definition to nursing student development.
The results of research have been mixed regarding whether clinical experience or general nursing education contributes to or correlates with a student's self-concept (Burgess, 1980; Ellis, 1980; George, 1982; Komorita, 1972; Nagel, 1982; Olson, Gresley, & Heater, 1984.) Scipen and Pasternack (1977) questioned senior students at the completion of a semester-long independent clinical experience and concluded that the experience had increased student self-confidence. Smith (1957), however, questioned how additional clinical experience could ever contribute to a student's self-confidence: The student, because she is being a nurse instead of learning to become one [during clinical experience], is bound to feel inadequate" (1957, p. 18).
Consistent with Smith's concerns, Meleis and Farrell (1974) found that nursing students rated themselves low on self-esteem. Yet, those responsibilities and technical tasks practiced during clinical experience, which may be confounding measures of self-concept, self-esteem, and self-confidence, may be contributing to the student's development of professional identity. Gendron (1981) noted that students' mastery of nursing skills "takes on the dimensions of a symbolic 'rite of passage,' transforming their self-concept from laymen to nurse" (p. 31). Even though a few studies have been directed toward the identification of a best method to achieve clinical learning, and indeed, even toward the identification of the learning that is to occur, conclusive results have thus far eluded researchers.
While education must be based on experience, it is clear that all experiences are not equally educative (Dewey, 1916, 1938). Infante (1975) described 14 elements that were essential in order to make a clinical experience an educational experience:
* opportunity for patient contact,
* objectives for activities,
* competent guidance,
* individuation of activities,
* practice for skill-learning, both motor and intellectual,
* encouragement of critical thinking,
* opportunity for problem-solving,
* opportunity for observation,
* opportunity for experimentation,
* development of professional judgment or decisionmaking,
* encouragement of creative abilities,
* provision for transfer of knowledge,
* participation in integrative activities, and
* utilization of the team concept (p. 22).
Infante found general agreement about the importance of these elements in a sample of baccalaureate nursing educators surveyed even though their reported clinical teaching behaviors did not generally demonstrate practice of these elements. Infante concluded by questioning the learning that occurred during clinical experience. The findings and conclusions were consistent with a study conducted some 8 years earlier by Zasowska (1967). In summary, although Dewey (1916) states that "an ounce of experience is better than a ton of theory" (p. 144), this investigator found no research to support why clinical experience comprises such a significant portion of the curriculum. This study will further explore two potential outcomes of clinical experience - identification of accurate clinical nursing judgments and the development of professional identity.
Two hypotheses were tested:
1. There will be a statistically significant increase in the identification of accurate clinical nursing judgments as a result of clinical experience.
2. There will be statistically significant progress in the development of professional identity as a result of clinical experience.
The study used a convenience sample of 16 baccalaureate nursing students from one university setting who were enrolled in a 60-clock-hour required clinical course at the beginning of their junior year. All subjects were also enrolled in a concurrent theory course. Volunteers were randomly assigned to the experimental group. The design was quasi- experimental and subject recruitment continued until an equal number were assigned to the control group. One group of eight subjects (the experimental group) had no clinical experience for a term so that their performance on the data collection instruments could be compared with a control group of eight subjects who had clinical experience as prescribed in the curriculum. Approval for implementation was obtained from the Institutional Review Board for the Protection of Human Subjects and all subjects signed informed consents. Subjects in the experimental group received $100 to compensate in part for inconveniences related to delaying this required clinical experience.
Characteristics of the Sample
The control and experimental groups were fairly similar in terms of age, ACT score, and grades obtained (Table 1). The subjects in the experimental group reported having had slightly more clinical experience prior to intervention, but all subjects reported a desire for additional clinical experience. Baseline measures of the two dependent variables also show the groups to be similar (Tables 2 and 3).
The identification of accurate clinical nursing judgments was measured by "Patient Care Problem Simulation," developed by Dincher and Stidger (1976). This 163-item clinical simulation was completed at the end of the term. Dincher and Stidger have reported content validity for the tool. A baseline measure of accurate clinical nursing judgments was obtained utilizing "Nursing Performance Simulation Instrument," developed by Gover (1971). This is a 126-item instrument with 53 items scored. Gover has reported test-retest reliability, internal consistency, predictive validity, and construct validity for the tool. Gunning (1981) has reported criterion validity for the tool.
The development of professional identity was measured by "Student Learning and Development in the Clinical Environment," developed by Christian (1974). This 49item questionnaire was completed at the beginning and end of the term. Christian has reported the content and construct validity of the tool. Consistent with Chickering (1969), the seven major areas for the development of identity are: achieving competence, managing emotions, becoming autonomous, establishing (personal) identity, freeing interpersonal relationships, clarifying purposes, and developing integrity.
Multiple other instruments were used to describe the sample. Pertinent to this report is an instrument developed for this research titled "Clinical Experiences." The tool was based on Infante's (1975) essential elements of clinical experience and yielded two scores: previous clinical experience and desire for additional experience. Content validity was assessed by professional and student review. In addition, clinical instructors were asked to assign a letter grade at midterm during the clinical experience immediately preceding implementation of this research project, and again at the completion of the subject's clinical experience for this term. Grades in the concurrent theory course were also recorded (Monahan, 1986).
The control group completed the approximately 60-clockhour clinical course providing nursing care to an assigned client under the supervision of an instructor. The course was the third of seven required clinical experience courses in the curriculum. The experimental group had no assigned clinical experience during the term, although they completed other course requirements that did not involve clinical experience. All subjects completed a theory course during the term. In addition to baseline data collection, subjects completed instruments at midterm and at the completion of the term.
The first research hypothesis would be statistically supported or rejected using a one-way analysis of variance (ANOVA) with a significance level of 0.10 to examine group means on the "Patient Care Problem Simulation." The second research hypothesis would be statistically supported or rejected using a one-way ANOVA with a significance level of 0.10 to examine group means on "Student Learning and Development in the Clinical Environment" at the end of the term. The secondary sources of data were collected in an effort to either demonstrate homogeneity in the subject pool or explore subject differences and thus limit the effects of nonrandomization. The level of statistical significance for accepting the hypothesis was set at the 0.10 level. This level was deemed to be sufficiently stringent for an exploratory study such as this one.
The first research hypothesis stated that there would be a statistically significant increase in the identification of accurate clinical nursing judgments as a result of clinical experience. The control group identified a larger number of accurate clinical nursing judgments than did the experimental group. This direction is consistent with the hypothesis (Table 4). The results of the one-way ANOVA were not significant. The directional hypothesis, therefore, could not be supported.
Professional Identity Prior to Intervention*
Clinical Nursing Judgment Prior to Intervention
Clinical Nursing Judgment After Intervention
The second research hypothesis predicted statistically significant progress in the development of professional identity as a result of clinical experience. (A lower score on "Student Learning and Development in the Clinical Environment" reflects a higher level of professional development.) Professional identity after intervention is displayed in Table 5.
An examination of the mean scores for professional development before and after intervention showed slightly greater progress in the development of professional identity in the experimental group, although the difference was not significant. The directional hypothesis was not supported; the mean scores did not change in the predicted direction. Subjects in both control and experimental groups demonstrated at least slight progress in the development of professional identity in all categories.
The subjects in the control and experimental groups were relatively homogeneous prior to intervention.
Clinical experience did not contribute to an increase in the identification of accurate clinical nursing judgments as measured by the instruments used for this research. While scores on the tool measuring clinical nursing judgment changed in the predicted direction, the difference was not significant. In the ANOVA, less than 0.5% of the difference between groups could be attributed to the absence of clinical experience. The large degree of variance on the total score within each group is noteworthy and may be a reflection of subject difficulty with the simulation itself.
Both groups showed progress in the development of professional identity. Although not significant, this progress was slightly greater in the experimental group. Without the demands of the clinical course, it is possible that the experimental group was able to devote additional time to components of developing a professional identity. Subjects in the experimental group felt better about their situation than did subjects in the control group and such feelings undoubtedly influenced any developing sense of identity.
In summary, clinical experience did not contribute to nursing judgment or to the development of professional identity. This conclusion is not consistent with theories developed by Benner, Chickering, and Christian. However, nonsignificant findings are consistent with the difficulty other researchers have experienced while attempting to identify the contribution of clinical experience to learning.
As the term progressed, the control group reported an increase in "previous clinical experience" and a slight decrease in their "desire for additional clinical experience." Thus, the members of the control group did indeed have a clinical laboratory experience consistent with Infante's (1975) definition of an educational experience. The experimental group, with no clinical experience during the term, reported a decreased amount of "previous clinical experience" at midterm followed by an increase in their reported "previous clinical experience" at the end of the term. It is indeed puzzling that these students who had no actual clinical experience during the term had a higher total score on "previous clinical experience" at the end of the term than they had at the beginning.
Professional Identity After Intervention*
Throughout the term, the "desire for additional clinical experience" decreased in members of the experimental group - in fact, it decreased more than it did among subjects in the control group who had clinical experience. If the reported decrease in "previous clinical experience" at midterm is ignored, the data would support a conclusion that members of the experimental group also may have been engaged in an educational clinical experience. While this is a possibility, it seems unlikely given the lack of a steady increase in the "previous clinical experience" score as the term progressed. Rather, it seems reasonable to conclude that part of the learning in a clinical experience may be learning the need for additional experience. Dewey (1938), for example, suggested that an educational experience illuminated the unknown as well as the known. The decrease in the "desire for additional clinical experience" in the experimental group appears large when compared to the incremental change of the control group, and seems to reflect the lack of clinical experience.
Delaying the clinical experience until after all theoretical material had been presented had no effect on subjects' theory grades and it is reasonable to conclude that clinical experience does not improve the grade in a concurrent theory course.
The conclusions drawn from this research have implications for nursing education. Granted, only limited generalizations can be made on the findings of this exploratory study because of the sample size. These findings, however, should not be confused with mere opinions regarding the usefulness of clinical experience so prevalent in current literature. The learning outcomes achieved through clinical experience in the nursing curriculum have yet to be identified. Without identification of these learning outcomes, there appears to be justification for questioning the large number of credit hours allotted to the clinical component of nursing education.
Clinical experience is not a goal in itself; rather, it has an educationally sound purpose. Yet without identification of learning outcomes achieved through clinical experience, there is reason to question spending the time and money that clinical experience requires. Additional research should be conducted to identify the learning that occurs during clinical experience; other instruments should be used and additional variables should be explored.
Given the fact that there were no ill effects on subjects in this research project and that a more dramatic difference between control and experimental groups will be necessary to isolate variables unique to clinical experience, further research should employ larger samples for a longer time.
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Characteristics of the Sample
Professional Identity Prior to Intervention*
Clinical Nursing Judgment Prior to Intervention
Clinical Nursing Judgment After Intervention
Professional Identity After Intervention*