The acquisition of knowledge and specific professional skills in nursing was originally acquired through an apprenticeship (Flexner, 1972). Experiential learning in the nursing curriculum provides the "apprentice nursing student* with clinical situations for integration of theory with the practice process. Torres (1986) concludes that the integration of theory with nursing practice is the basis for professional nursing, adding that it is impossible to provide nursing care without processing knowledge in some way.
The experiential learning model of KoIb (1984) provides a framework for examining the selection of learning activities. He believes that the most effective learning is that which emanates from personal experiences, hence his identification of concrete experience as the first stage in the learning cycle. Duley and Permaul (1984) write that experiential education causes students to apply knowledge gained vicariously in the classroom to action-oriented skills.
Nursing faculty in clinical settings are charged with providing students with the best possible patient-centered learning experiences. These concrete experiences serve to enhance the nursing student's affective, cognitive, and psychomotor development. Karuhije's (1986) writing on the education and preparation for clinical teaching explores the adequacy of educational preparation of clinical educators. Carpenito and Duespohl (1981) spoke to the issue that students who perform professional nursing acts during their clinical experience must complete these acts with the same degree of competence as the professional nurse.
Goldenberg and Iwasiw (1988) concluded in their study of Canadian nursing faculty that the selection of patients by faculty should be a rational process. They add that graduate programs that prepare nurse educators should include the patient selection process in their curricula.
Because the patient is the focus of clinical practice, the patient selection process is central to the patient-nursing student interactions. There are no identified standards, however, regarding a consensus of factors used in the student-patient matching process. The purpose of this study was to identify factors used by clinical educators in the selection and matching of patients with students and to rank the importance of each factor.
The sample consisted of 139 full-time nurse educators teaching in an associate degree program with at least one year of academic and clinical teaching experience. Twenty-four of the 34 accredited programs throughout the state provided faculty respondents.
A mailed questionnaire was used to obtain data for this exploratory, descriptive study. The first section of the questionnaire identified different categories to be considered during the patient selection process. These categories focused on the (1) patient, (2) nursing student, (3) clinical unit, (4) clinical unit nursing staff, (5) nursing program curriculum, and (6) clinical educator. To measure the degree of importance of each item, a Likert-type scale was provided.
The second section of the questionnaire asked the respondent to review each category item in order to select and then rank the five most important items in their student-patient matching process. The third section requested information to study demographic variables.
Means and standard deviations were determined for each item in each of the six categories. Frequencies and percentages were used to identify the respondent's selection and ranking of the five items perceived as most important in the patient selection process. Frequencies and percentages were completed for each of the eight demographic variables to illustrate the characteristics of the sample.
ANOVA was performed on each category item using the eight demographic variables to identify the most promising relationships to be studied further. The level of significance was set at .01 for the p value. One-way ANOVAs (confirmed with Tukey's HSD) were completed on significant relationships. Factor analysis was also carried out to confirm the factor patterns. Extraction was set at five levels (factors) and satisfied the purpose of the procedure.
The following presents the six categories and the one item per category perceived as having the most importance (highest mean) in the patient-student matching process. The categories and items are:
(1) Patient - physical care,
(2) Nursing student - learning needs,
(3) Clinical unit - policies/procedures defined,
(4) Unit staff - staff and educator interaction,
(5) Program curriculum - matehing course and clinical objectives, and
(6) Clinical educator - legal implications of role.
The first of the five items selected from all of the questionnaire items and ranked as the most important was the matching of clinical and course objectives. The item ranked second in importance in this matching process was the physical care of the patient. The third most important item was the specific learning needs of the student. The fourth and fifth ranked items again identified the item of matching course and clinical objectives.
To investigate the relationships, ANOVA was completed for each questionnaire item with each demographic variable. The variable, student-educator ratio, indicated a level of significance (p = .01) with the legal implication of the educator's role. Another variable, teaching assignment, also indicated a level of significance (p = .01) with the item relating to the patient's ability to cooperate.
One-way ANOVAs (confirmed with Tukey"s HSD) were completed with the teaching assignment variable and two items having a level of significance of .00. These two very significant items were the students' previous courses completed and their college laboratory skill preparation.
When educators rated each item in the six categories, the physical care of the patient had the highest mean, indicating that this information is of primary importance to the student matching process. It should then be noted that the physical needs of each patient should be carefully reviewed and matched with the learning needs of the student for an optimal situation.
Matching the clinical and course objectives was the item rated next as having the greatest importance. The clinical and course objectives are usually predetermined and provided in writing to the clinical instructor and the student. The student gains learning experiences through individual assignments, but should also be aware of learning opportunities with peer assignments, staff and physician interaction, etc. The importance of formative and summative evaluation of student clinical experiences can also aid the program director in future contractual agreements.
Learning needs of each nursing student was the third item rated with a high level of importance. The clinical instructor must have knowledge of each student's psychomotor skill competency, ability to understand and implement the nursing process, and ability to organize and prioritize the assignment. Knowing the student's individual needs, the instructorcan then focus on the development of these specific needs through the patient-student interaction.
These three items were rated highest in their categories and were also selected and ranked as the items having the most importance to the patient-student matching process. It is noteworthy that when the demographic variables were analyzed with every item, four different questionnaire items were identified as significant.
When the clinical ratio variable was analyzed with the instructor role item, the data indicated that this item was significant. This suggests that as the clinical ratio and number of student-patient matehing situations increase, the instructor has an increased level of accountability and the potential for legal implications increases.
When the teaching assignment variable was analyzed with the item on patient's ability to cooperate, the instructors assigned to beginning students indicated that the patient's being cooperative was very important in their matching process. The patient's being cooperative can enhance learning and strengthen competencies rather than distracting the student who is attempting to demonstrate a competency with a patient who is not cooperative. Advanced students have more clinical experience and are better prepared academically. Patient cooperation is less important to the instructor in specialty rotations (obstetrics, pediatrics, gerontology, etc.) where certain behaviors may be anticipated. The lack of cooperation by a patient may then provide a specific challenge to the advanced student and the instructor.
The teaching assignment variable was analyzed with previous nursing courses and the college laboratory skill preparation of the student. The data indicated that these items were both important to clinical instructors in medical-surgical and basic teaching assignments and less important to the specialty area clinical instructors. When selecting patients for the basic-level student, the clinical instructor should have knowledge of the student's academic progress as well as the laboratory skill preparation. Having this information before matching the student with a patient might avoid an inappropriate, unsafe selection. Students in the medicalsurgical area have completed more nursing content, laboratory skills, and clinical experiences; therefore, the patient selection process can lend itself to the selection of a more complex, challenging patient to demonstrate the achievement of cognitive, affective, and psychomotor skills. The specific learning needs of every student should be paramount to the clinical educator during the student-patient matching process in order to select clearly delineated experiences.
Because the patient is the focus of the nursing standards of practice, increasing the structure of experiential learning will better prepare the nursing graduate entering the profession. Identification and importance of the factors used in the patientstudent matching process can serve to improve the nursing curriculum through increased standardization of the clinical experience.
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