Baccalaureate nursing graduates are expected to possess management competencies in the clinical practice setting (Primm, 1986). The American Association of Colleges of Nursing (1986) identifies planner/coordinator as one of the three major roles of the nurse, and the National League for Nursing (NLN) expects that the undergraduate curriculum "provides for the development of skills in leadership and management for beginning professional practice" (1983, p. 7).
The purpose of this study was to identify baccalaureate nursing students' perspectives of a clinical nursing leadership experience. The leadership experience was designed to provide students the opportunity to practice specific leadership and management skills needed for entry-level positions as team leaders and primary nurses.
Review of the Literature
Joyce-Nagata, Reeb, and Burch (1989) assessed whether the competencies of graduates of baccalaureate degree nursing programs as developed by the NLN in 1978 were evidenced in the work setting. They found that administrators felt that 16 of the 64 competencies were not demonstrated by the graduates; one not demonstrated was "functions effectively as a leader in the delivery of health care" (p. 319).
Approaches used by nurse educators to enable students to acquire clinical skills and to exhibit attitudes and competencies thought to be associated with success in clinical agencies have met with varying levels of success. Reported strategies include the use of preceptorship programs and clinical courses designed to achieve specific goals.
Clayton, Broome, and Ellis (1989) studied the effect of preceptorship on the socialization of baccalaureate graduate nurses into roles of professional nurses. Findings indicated that six months after graduation a preceptorship group scored higher on the subscales of leadership, teaching/collaboration, interpersonal relations and communication, and planning and evaluation than did a group who had a traditional course. The authors concluded that working with a practicing nurse in the clinical environment, as opposed to with a faculty member, will enhance the transition to staff nurse. They felt that their findings support the andragogical premise that adults learn more effectively in a one-to-one situation than in a group situation.
The effectiveness of a senior preceptorship experience as a method for promoting anticipatory socialization to the working role was assessed by Dobbs (1988). There was a significant decrease in the total role deprivation score after experiencing the preceptorship. Based on the findings, Dobbs felt that students learn to cope with the differing demands of the role in the work environment. She also suggested that it can be expected that graduates who have learned to make satisfactory compromises between differing role values should experience less role deprivation during their first job.
Scheetz (1989) found that students who participated in summer preceptorship work experiences demonstrated a greater gain in competence in problem-solving, application of theory to practice, and psychomotor skill performance than did students who participated in summer work experiences in noninstructional clinical settings.
However, when Itano, Warren, and Ishida (1987) compared students participating in a preceptorship program with students in a traditional faculty-supervised clinical group, they found no differences between the two groups in professional and bureaucratic role conception scores and role deprivation scores. The authors suggest that both methodologies may be viable and valuable learning experiences.
Using a qualitative approach, Pierce (1991) ascertained how undergraduate preceptorial students view their clinical experience. Two overall themes emerged: what students desired from their clinical experience, and the factors that influenced that experience. Students want to learn within an environment conducive to that learning. Preceptorial students need as much, if not more, guidance than the instructed student. Pierce suggested that it may be that preceptorship hastens the professional growth of students. By providing a more realistic view of nursing, it may reduce reality shock.
Hughes, Wade, and Peters (1991) investigated the effects of a 15-week Synthesis of Nursing Practice course on senior nursing students' self-concept and perception of role competencies. The goal of the course is to facilitate the transition from nursing school to the real work world. Findings indicated a significant increase in the students' self-concept and perceived role competencies. The authors felt that the course enabled the students to strengthen their technical skills, manage patient care assignments similar to the staff nurses' duties, and build selfconfidence, which in turn enhanced their self-concept and perceptions of role competencies.
Olson, Gresley, and Heater (1984) investigated whether an eight-week clinical course would enhance students' self-concepts and increase their perception of competence in critical care, teaching/collaboration, planning/ evaluation, professional development, leadership and interpersonal skills, and communication. Results showed no differences between a control group and the interns who completed the course. However, the number of subjects in the intern group was small. The authors proposed that the benefits of an internship may not be as readily present as is currently believed. They also stated that the nursing program in which the study was conducted provides a strong conceptual and practice base for students and the internship did not greatly increase this base.
In summary, preceptorships and synthesis of nursing practice courses have been reported to be successful regarding gains in clinical competence, enhanced socialization, and decrease in role deprivation. However, one study evaluating preceptorship and another evaluating use of a clinical course failed to demonstrate favorable results in regard to role conception and perception of clinical competence. The studies reported in this literature review were conducted in a variety of settings and with different curricula. All of the authors agree that further research is needed regarding both clinical teaching methods and selected clinical learning experiences to identify optimum learning opportunities that yield the desired outcomes.
This study was conducted to acquire insights from the students' perspectives about a planned experience designed to help them acquire the leadership/management skills required of beginning practitioners. Insights about perception of clinical competence and about the acquisition of positive role conception were of special concern.
The study employed a qualitative descriptive design using Colaizzi's (1978) phénoménologie method of protocol analysis. This method was chosen to gain the students' perspectives of the leadership experience as they were involved in it.
The sample consisted of 27 senior baccalaureate nursing students who were concurrently enrolled in a threehour nursing leadership theory course and in a five-hour acute care clinical practice course. The investigators explained the purpose and requirements of the study and that participation was voluntary. Students were assured that exclusion from the study would not in any way affect their experience or grade. Informed consent was obtained.
The clinical leadership experience was one of the assignments for the acute care clinical practice course. It consisted of three eight-hour days in which students were assigned to work with registered nurses functioning as team leaders or as primary nurses. In addition to the discussions about clinical leadership and management in the leadership theory course, students participated in pre-experience conferences in which their role was outlined, and specific responsibilities and application of leadership and management principles were discussed.
The data collection process involved three phases:
* The pre-experience phase focused on expectations of students. Students participated in a focused group interview, which was tape-recorded, and responded to the following prompts: What are your thoughts and feelings about what a team leader does? Is this important? Why or why not? What qualities do good and had team leaders have? What are the best and worst things that can happen during the experience? What are your expectations of this experience?
* The process phase focused on the phenomenon as the student experienced it. Students completed a written log describing their feelings during the leadership experience. Prompts included: Describe what you did in your role as team leader and compare it with what you thought you would do. Compile a list of activities that made you feel like a leader.
* The postexperience phase focused on retrospective evaluation. In focused group interviews, again taperecorded, students responded to the following prompts: Describe your perspectives and feelings during your leadership experience. Have your perceptions changed? What were the best and worst things that happened? Data from the pre-experience phase were shared with students in order to allow them to clarify their perspectives about what happened compared with what they thought would happen. An example of this type of prompt is: During your pre-experience interview, you stated that leaders knew everything about everybody. How do you feel about that now?
The research proposal was developed with the consultation of an experienced qualitative researcher. After the initial proposal was developed, a pilot was conducted with a group of 10 students. After review of the pilot findings, and in consultation with the experienced qualitative researcher, the questions that the students responded to during the three phases were revised. As a result of the pilot, the proposal was significantly revised to examine student responses acquired during the pre-experience phase interview and to share the responses with the students during the post-experience phase interview. Students were then asked how they felt about their initial responses now that the leadership experience had been completed.
Analysis of Data
The analytical process adapted from Colaizzi (1978) was used. The procedural steps for analyzing the data obtained via tape recordings and written logs included:
1. Acquiring a feeling for protocols (subject's descriptions), making sense of them.
2. Extraction of significant statements.
3. Formulation of meanings.
4. Organization of the aggregate formulated meanings into clusters of themes.
5. Integration of themes into an exhaustive description of the phenomena of interest.
6. Formulation of the exhaustive description of the investigated phenomenon in as unequivocal a statement of identification of its fundamental structure as possible.
7. Validation of findings with subjects.
To ensure that the formulated meanings did not sever the connection with the original protocols while moving beyond the protocol statements, samples of the restatements and formulated meanings were reviewed by a doctorally prepared judge experienced in phenomenology. Her critique of these samples was used as a guide throughout data analysis.
Upon completion of data analysis, the findings were shared with 12 of the 27 subjects. The formulated meanings, themes, and the exhaustive description were validated by the 12 subjects.
Findings and Discussion
Themes that emerged from the sets of data reflecting the students' perspectives for the three phases of the leadership experience are presented. Conceptualizations of acquisition of clinical nursing skills by baccalaureate nursing students found in the literature are discussed in light of the students' perspectives identified in selected themes.
Three themes emerged from data analysis of the pre-experience phase: anticipatory anxiety, anticipation of role, and anticipated outcomes.
Anticipatory anxiety. Anticipatory anxiety was manifested in several ways. First, there was diffuse anxiety related to nonspecific concerns. Second, students were concerned with communication, specifically, taping changeof-shift reports, telephoning, and collaborating with physicians. Third, students anticipated stress related to managing role functions. They had an inflated view of the functions and questioned their ability to carry them out, making such comments as "all the things you have to do." Last, students experienced anxiety "related to the unknown."
The pre-experience anxiety of the students in this study is consistent with Windsor's (1987) findings regarding nursing students' perceptions of clinical experience. Her data reflected a pattern of development in which students experienced anxiety and obsession with the rules of task performance in the early phase of clinical experience. In their study of nursing students' perceptions of anxietyproducing situations in the clinical setting, Kleehammer, Hart, and Keck (1990) reported that students expressed the highest anxiety for the initial clinical experience on a unit and the fear of making mistakes, and that clinical procedures, hospital equipment, and talking with physicians were anxiety-producing. Students in our sample were concerned with communication and were anxious about performing appropriately as leaders.
Anticipation of role. While students could identify the textbook concept of carrying out the leadership role, they were concerned with what was done and how it was done. Their comments revealed that they had an inflated view of the role when they used phrases like "everything," or "total chaos." For example, they commented, "She assumes total responsibility for a floor," and "I think there would be total chaos on the floor if there wasn't a team leader."
Students had definite ideas about the qualities of leaders, expecting them to have a good speaking voice, be confident and keep a high morale, and "mediate, organize, and set the emotional tone when a problem arises so that the primary concern, patient care, is done properly." They felt leaders should be knowledgeable resource persons and teachers. They identified bad qualities as being disorganized, moody, and not expressing appreciation for contributions of team members. They did acknowledge that team leaders are human and may make mistakes.
Anticipated outcomes. This theme evolved from several ideas. Students valued the anticipated experience and had positive expectations as exemplified in the statement, "My biggest goal is to see it all come together from a management standpoint." Students expected to provide the best care through leadership. The statement, "What a team leader does - you can make sure the patient is getting the best care that they can get," exemplifies this idea. Last, students enthusiastically expected to apply formal classroom learning and acquire management skills.
In Pierce's study (1991) about students' views of the preceptorial experience, students wanted to feel like a nurse, to give good care, and to make a difference to the patient. This is similar to our finding that students anticipated using leadership to provide good patient care. This valuing of skill acquisition correlates with the finding by Beck and Srivastava (1991) that new learning experiences was one of three primary areas of satisfaction for nursing students.
During the leadership activity, students experienced emerging clarification of the leadership/management role. Students revealed that their pre-experience expectations were met relative to activities such as assessing, checking orders, and assigning staff Perspectives that were modified as a result of being intimately involved in clinical leadership activities included becoming aware of support systems and of the fact that leaders were involved in direct patient care. The responsibility of the role became more crystallized for them.
Activities that made the students feel like leaders included giving and receiving reports, making patient care assignments, admitting and discharging patients, completing acuity reports, checking orders and updating the stani and assessing patients.
Themes included validation of role model and integration of leadership skills into behavioral repertoire, emerging sense of confidence, active involvement enhanced acquisition of leadership skills, and entrance into the system.
Validation of role model and integration of leadership skills into behavioral repertoire. Several perspectives comprise this theme. First, students clarified the responsibilities of the leadership role and modified some of the pre-experience perspectives. They found that, as leaders, they "did a lot more patient care* than expected, and that "It wasn't so overwhelming." Some related that the experience "put a completely different light on what is involved in the role." They discovered that verbal and written communications are time-consuming and time must be allotted to complete them. They had to "learn to work with interruptions.'' They recognized the need for delegation, and while they practiced it, some acknowledged problems with this activity. They developed evaluative skills, identifying the consequences of delegating improperly. Some were concerned with task orientation. For example, one student commented, "we pitched in and actually did whole patients just so that we knew the work was getting done." Higher-level professional activities were described as, "reporting significant changes to the charge nurse and making major decisions together." The leadership role was further defined regarding supervision of staff in providing care to a group of patients. A value system emerged for the students. "The leadership rotation does make a difference as far as organization, dealing with the people on your team and getting along; if any discrepancies come up, you're the one that has to deal with the problems." Finally, students identified with the role as evidenced by comments such as, "You know what a good team leader looks like and it gives you something to shoot for."
Clayton et al. (1989) demonstrated the value of a preceptorship experience in enhancing professional socialization. Precepted students scored higher on leadership, teaching/collaboration, interpersonal relations and communications, and planning and evaluation over time. The perspectives shared by the students in the current study resemble these professional socialization scales. Dobbs (1988) found that a preceptorship experience is effective in promoting anticipatory socialization. The preceptorship resulted in changes in role expectations and enabled the students to increase their competencies and to learn to cope with the demands of the work environment. The perspectives of the students in the present study indicated that they had acquired clinical skills and that they had a clearer idea of the responsibilities of the leader. They also verbalized positive feelings about coping with demands of the work situation.
Emerging sense of confidence. Students acknowledged that they acquired skills to handle role requirements and that this "boosted the confidence in ourselves." Support systems were noted: "Before the experience I thought I'd be very anxious about having the responsibility, but I didn't feel that way when I was doing it because there was someone there guiding me and I felt more capable and confident." A part of this emerging sense of confidence related to mastering the worst experiences, which were patient and family problems requiring interpersonal skills. Acquiring a feel for reality helped also. As one student stated, "I thought that I wouldn't get everything done ... I figured there had to be a lot of things to do, and there is no way to get them all done. So you learn to prioritize ..." Another said, "If you have confidence in yourself and in your decisions, and can admit freely when you don't know something and go to a supervisor to find out, you earn a lot more respect."
This emerging sense of confidence correlates with Windsor's findings regarding nursing students' perceptions of clinical experience. Her data reflected a pattern of development in which students were anxious in the initial phases of the experience. They felt more confident and comfortable in the later phases about not knowing everything because they felt they could find the answers.
Hughes et al. (1991) identified that self-concept and perceived role competencies scores increased significantly between the beginning and the end of a Synthesis of Nursing Practice course. While self-concept was not addressed specifically in the data collection for our study, students reported that they felt more competent and confident in decision-making, and that they could earn respect by consulting textbooks and supervisors when they did not know something.
Active involvement enhanced acquisition of leadership skills. The concept that the registered nurse leader gives students access into the system and permits them to be actively involved was significant. "The first one would let me pretty much be in charge. She wouldn't let me do anything horribly wrong, but she was letting me be team leader." While students wanted to be involved actively, they also wanted validation that they were acting appropriately. Assertiveness on the part of the student and explanation of the student role were helpful in resolving with the staff the role of the student in learning to carry out leadership activities. Another major perspective was that being able to emulate role models with positive qualities enhances active participation. A student put forth this idea, "I learned that my RN team leaders had just graduated . . . but they were good at it, competent. It showed me that I can do it."
For undergraduate preceptorial students in Pierce's (1991) study, a good clinical day occurred when help was available and when there was positive interaction with staff A bad clinical day was associated with only being allowed to observe. The students in our study shared similar perceptions.
Dobbs (1988) found that preceptorships promote anticipatory socialization to the working role of professional nurses, and emphasized that the role has to be practiced, not just observed. Students in Windsor's (1987) study felt that staff were supportive and that this was helpful. This idea of supportive staff was evident in our findings in which staff nurses assisted in providing entry into the system and setting the atmosphere for active involvement.
Entrance into the system. As a result of the experience, students felt that they had gained entrance into the system. There was acknowledgement that they had acquired skills for the leader role. One student verbalized, "They came to me. There were licensed practical nurses and nursing assistants and they came to me." Being a part of the system and functioning as a leader in it was evident when they shared the perspective that they were aware of the situational support system. This was closely related to the idea that The team is it, I'm not it." "If you're in a team environment where people really do want to work together it goes very well. You aren't isolated. There's a lot of room for growth. I feel good about that."
Prior to the clinical leadership experience, students felt anticipatory anxiety. While some of the anxiety was diffuse, some resulted from anticipation of taking on role functions. The anxiety may have been heightened by their inflated view of the responsibilities of the leader, by their questioning of their ability to handle the role, and simply by the unknown. Students were excited about the learning opportunity and held positive expectations about acquiring specific management skills and seeing it all come together.
During the actual experience, students' expectations regarding specific activities were supported in some areas and modified in others. They became aware of available system supports, appreciated the responsibility of the role, and recognized that leaders may provide direct patient care. Students felt like leaders when involved in activities such as giving and receiving report and by making assignments.
As a result of the experience, students demonstrated a degree of cultural acclimation. They modified some preexperience perspectives and clarified their ideas, resulting in a clearer definition of the leadership role. They experienced an emerging sense of confidence about their management and leadership ability. A value system prizing the professional nursing leadership needed for managing patient care evolved. They emulated leadership qualities in respected nurses, adding desirable ones to their repertoire of skills. They had to acquire entrance into the system and be actively involved in practicing leadership activities to acquire the skills.
The ability of baccalaureate nursing graduates to function effectively in managing care for a group of patients is a valued skill. The findings of this study support the value of a leadership/management experience in the undergraduate curriculum. When planning an experience, faculty should be cognizant of anxiety felt by students and the sources of the anxiety so that appropriate support can be provided. Findings suggest the need for faculty to plan experiences with nursing service whereby students can be actively involved in management and leadership activities, and work with professional nurses who serve as good role models. Findings also suggest specific student learning needs related to management, such as how to use time efficiently and how to delegate effectively.
Since generalizability is limited as data were collected from one site, it is suggested that replication of the study be completed in a variety of settings. It is also suggested that different research methodologies be employed to identify optimum learning opportunities in which students can acquire entry-level clinical leadership skills. Follow-up studies of performance of graduates is also recommended.
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