A major component of basic nursing educational programs takes place in a clinical practice setting. Although all learning takes place within a social context, the context of clinical practice includes many more variables than the traditional academic setting. Several researchers have reported studies of various aspects of the learning process in basic nursing education programs from the perspective of the student.
In The Silent Dialogue, Olesen and Whittaker (1968) recorded the progress of young, American, middle-class women through the three years of a new, innovative baccalaureate degree nursing program. The emphasis was on the student culture. The process described by Olesen and Whittaker enabled the students to emerge at the completion of the program with a set of attitudes and values that made up their professional identity. The process of learning knowledge and skills was assumed but not described.
Beck (1991) examined student perceptions of faculty caring. The focus of this research was on the studentteacher interaction without regard to where it took place. Of the 47 incidents included in the study, only eight described an interaction in the clinical setting. Characteristics of the caring interaction were attentive presence, sharing of selves, and positive consequences.
By contrast, in Theis* (1988) study of nursing students' perspective of unethical teaching behaviors, 50% of the 216 incidents described occurred in the clinical setting. The largest number of incidents involved lack of respect for the students.
Flagler, Loper-Powers, and Spitzer (1988) found five dimensions of clinical teaching in which the instructor was resource, evaluator, encourager, promoter of patient care, and benevolent presence. All of the behaviors except the evaluator items were rated by the students as helpful to the development of their self-confidence as nurses. Several researchers have reported the anxiety-producing nature of the clinical practice for learners (Kleehammer, Hart, & Keck, 1990; Kushnir, 1986; Pagano, 1988) and the importance of faculty behavior to enhance student learning (Knox & Mogan, 1985; O'Shea & Parsons, 1979; Wong, 1978).
Two naturalistic studies of clinical experience from the student perspective were identified, one in the United States and one in Great Britain. Windsor (1987) examined nine senior students' perceptions of their clinical experience during the entire program and described a developmental process. Major learning areas identified by the students were nursing skills, time management, and professional socialization. Students described the instructor as an important component of clinical learning who could be either a negative or a positive influence. Melia (1982) used a grounded theory approach to student accounts of being learners in nursing and used the data to construct the students' view of the nursing world. None of the studies of the student experience of learning combined observation and interviewing for data collection.
The purpose of this qualitative study was to explore and describe nursing students' experience of learning within the context of one clinical practice setting where the students learned to provide nursing care for acutely ill infants. Only a subset of the findings are reported in this paper.
The participants were students in a senior level clinical practice course in a baccalaureate nursing program in a large university. During the six-month data collection period, 12 groups of students with two different instructors were assigned to the pediatrie nursing units for clinical experience. Students were included in the study if they were assigned to provide care for a patient in the infant section of the nursing unit. All participants gave informed consent.
In order to identify the components of the nursing students' experience of learning, the researcher observed students in a pediatrie clinical practice setting for approximately 75 hours over two semesters. The students and researcher did not interact during the observation times. The observation was carried out in two- to three-hour blocks and included observations of students providing care to patients as well as student interactions with instructors, staff nurses, and family members.
In addition to the observation in the clinical unit, the researcher interviewed 30 students within 24 hours after an observation period. The in-depth interviews began with broad questions such as "Tell me about your clinical experience today" and lasted approximately one hour. Questions asked during the interviews evolved over the duration of the study as themes emerged from the data analysis. A portion of each interview was developed after transcribing and rereading field notes from the observation period.
Data collected using these techniques of observation and ethnographic interviewing were analyzed using the procedures outlined by Spradley (1980). The findings reported in this paper were based primarily on the interview data.
Qualitative research models are cyclic rather than linear. The researcher enters a cyclic process of asking questions, collecting data, and analyzing data again and again. Asking questions and making observations appropriate to the questions is the basic cycle of interpretive research. The questions determined the nature of the observation; the answers to each set of questions determined the next set of questions throughout the data collection process.
Data were recorded in the form of extensive field notes and verbatim transcripts of tape-recorded interviews. These data were transcribed and analyzed daily. During initial analysis, data from field notes and interview transcripts were coded into domains or categories of meaning.
In later analysis, taxonomies provided a larger picture of the ways in which domains were related. Kinds of student goals was an important taxonomy that developed from the taxonomic analysis. In the final stage of data analysis, a search for an organizing, unifying theme for the data produced the idea of a nursing student perspective.
Several strategies appropriate to qualitative inquiry were used to minimize researcher bias or error in data collection and analysis and to increase rigor. First, the use of both observation and interviewing allowed the researcher to compare explanations of behavior derived from data collected by one technique with data from the second technique. Second, as hypotheses emerged from the data, the researcher returned to the setting to search for negative evidence. This testing of hypotheses against the daily reality of the social setting is an important factor in credibility. Third, these same hypotheses were also shared with participants from the setting to elicit feedback that aided in confirming, revising, or rejecting the researcher's emerging hypotheses. Finally, experienced qualitative researchers reviewed the data and data analysis (LeCompte & Goetz, 1982; Lincoln & Cuba, 1985; Sandelowski, 1986).
The idea of perspective is the organizing theme for the findings of this study. Nursing students developed a perspective as they interacted with the clinical education environment. This perspective then served as a guide to their actions within and in relationship to that environment. Included in this perspective were student goals, the types of actions that were consistent with these goals, the criteria for goal achievement, and student perceptions of student, instructor, and staff nurse roles. This perspective, then, was a shared understanding of what the world of clinical nursing education was like for the student. It included ideas of expected and permissible behavior. The perspective provided students with an understanding of why they were in the clinical practice setting and what personal outcomes they could expect. The perspective was shared by students with different instructors across the senior year.
Six major goals for the clinical practice experience as perceived by the student emerged from the data analysis:
* to cause no harm to a patient,
* to help patients,
* to integrate theory-based knowledge from lecture and eading into clinical practice,
* to learn nursing clinical practice skills,
* to look good as a student, and
* to look good as a nurse.
These six goals formed the framework for the perspective that guided student behavior in this clinical practice course.
To cause no harm
The most obvious fact about the clinical practice setting for the students was that they were expected to learn by caring for real people. This was both exciting and anxiety-provoking for the students. A constantly recurring theme in the interview data was the students' concern about the possibility of harming a patient through their lack of knowledge or skill. The goal of doing no harm had the highest priority in determining student actions. Students always evaluated possible actions toward the other five goals in the context of this goal. They rejected potential actions that might cause harm to the patient, and chose alternative actions that protected the patient. The students developed strategies for achieving the other goals that were consistent with this first goal.
The fear of harming a patient was a major motivation for student preparation before the clinical experience. The goal of doing no harm provided the students with a sense of urgency and necessity about their learning that was not present for learning in the classroom courses. As one student said:
One thing that motivates me is "what if?" What if this happened to your patient? Are you competent? Do you really know what you're doing? Are you going to be able to handle it?
An implication of this goal for the students was that, in order to accept the responsibility of patient care assignments, they moved out of the role of student and into the role of nurse. To the students, a student role implied that mistakes and learning by trial and error were acceptable. In the student role, they were responsible only for themselves; their learning behavior had consequences only for their own lives. However, in the nurse role they were responsible for another person's Me and well-being. If there was a choice between risk to the patient and risk to the student's grade or self-concept, the patient came first:
I feel that it's better to get caught asking the questions than to get caught making a mistake because you didn't ask. So I would rather eeem stupid than compromise my care of the patient.
To help patients
The second goal was closely related to the first. The students wanted to help their patients by making some positive contribution to their care. For the students, clinical experience was much more than an opportunity to learn. Working with patients in a clinical setting was the students' opportunity to help people. The students' career goals and motivation for choosing nursing as a profession were major factors in shaping this goal. The students wanted to make a unique contribution to patient care. They wanted to do something no one else thought to do or would take the time to do. The contributions students made to the patients* care were a partial justification for their presence on the clinical unit. They were doing more than just practicing on patients.
Integration of theory into clinical practice
Almost every student described in some way the process of applying facts and theories learned in a book or classroom in the day-to-day nursing care of their patients. Students reported that they were able to understand some classroom and reading material only after they observed or practiced the clinical application. Using the content presented in the classroom in a clinical setting also increased the students' retention of the newly learned facts, concepts, and theories:
I learn much better if it's taught to me in class first, then I go on the floor and I say "Okay, there's a little kid with leukemia, now this is what's going on with him." I relate it back to what I learned in class and that way it sticks in my mind. If not, I don't retain it.
Learning nursing clinical practice skills
The students, who frequently identify nursing with highly visible psychomotor skills, expressed frustration over what they perceived as inadequate skill practice. When asked in interviews how they would alter the clinical course to improve their learning, most students replied that they need to learn more skills, that they needed more clinical time. This was true at the beginning and the middle of the senior year. Students focused much of their behavior in the clinical area on the learning of psychomotor skills. When students reported in the interview what they had learned that day or week, they usually Usted the technical skills they had done for the first time or were able to do without help for the first time. Although nursing clinical practice skills certainly are not limited to psychomotor technical skills, it was these skills that were the core of this goal.
The fifth and sixth goals were related to evaluation and self-concept. Looking good was an essential part of the process of becoming a nurse. The students needed to look good academically in order to get good grades and to remain in the program. They needed to look good to instructors, staff, peers, and patients. The achievement of this goal provided some of the positive feedback that helped them to develop the inner sense of competence and confidence that they would need to practice nursing. The students needed to look good to themselves.
Goffman (1967) described the process of maintaining face as an encounter or interaction where the person's presentation of self to others is consistent with the internal sense of self and is supported by the reactions of the other people in the interaction. Looking good is a way to maintain face. Students who are in the process of developing an internal and external image of themselves as nurses are placed in a more precarious situation simply because they are still learning to be nurses.
During early data analysis, looking good appeared as a single goal. But as data collection and analysis progressed, this overall goal of looking good appeared to prompt behaviors that were inconsistent. Through further observation, interviewing, and analysis, looking good was divided into two parts: looking good as a student and looking good as a nurse. The students frequently used very different, even contradictory, behavior to reach each of these two goals.
The students wanted to look good to the instructor because of their perception that the instructor was always collecting evidence for their grade. Students were constantly aware that the instructor was evaluating them. Although the instructors used a clinical evaluation instrument to assign grades, the students were frequently uncertain about just what knowledge or behavior the clinical instructor was expecting. They were very aware of the evaluative aspect of student-instructor interactions. There was a continuing process of finding out what the instructor wanted.
During interviews, students alluded to some standard of perfection that the instructor expected and against which they would be evaluated. Components of this standard of perfection included answering all questions correctly, making no mistakes in skill performance, and always being involved in learning activities. Having the right answers in the student-instructor interaction was the most commonly identified criterion for looking good as a student. The students believed that almost every answer and action during the student-instructor encounter would delete or add points to their final grade:
There's a tot of pressure here. You have to do it right and if you don't, points are taken off your grade. You try not to think about it. You try to think about the patient but you can't help it when you know the instructor is watching you.
The goal of looking good as a student guided the students' interactions with their instructors. Students approached or avoided instructors based on how confident and competent they felt. They approached the studentinstructor interaction as an examination rather than as a learning experience. For many of the students, learning in the clinical experience took place outside the context of the student- instructor interaction.
I don't like to ask the instructor very much at all. First, I would exhaust all my sources and then I would ask my instructor. I had an instructor once who held it against me that I asked questions. It came back in my evaluation.
Goffman (1967) described the management of threats to face (looking good) in ordinary human interaction.
The surest way for a person to prevent threats to his face is to avoid contacts in which these threats are likely to occur. Once the person does chance an encounter, other kinds of avoidance practices come into play. As defensive measures, he keeps off topics and away from activities that would lead to the expression of information that is inconsistent with the line he is maintaining (pp. 15-16).
The second looking good goal formed from each student's need to acquire an inner sense of competence as a nurse. This goal was closely related to the goal of helping patients, in that the feeling of accomplishment that resulted from helping a patient contributed to the students growing sense of competence. Achieving the goal of helping patients was one way to look good as a nurse. Positive feedback from patients and families was important evidence that a student was achieving this goal. Successful performance of aspects of nursing care that the students had not previously mastered also added to their sense of competence. Looking good as a nurse included students' organizational skills. The students examined their own feelings of comfort and competence in the midst of the clinical experience and used their level of anxiety about performing nursing care as a measure of their competence as a nurse. When their anxiety level was low and they felt comfortable doing the nursing care, the students felt an increased competence.
I feel like I've done well in clinical if I feel that I'm doing good for the patient . . .if Isee some sort of improvement, or I know something important and I do something about it. If I just do procedures that are going to be done anyway, I don't feel like I've accomplished anything.
Feedback from staff nurses had an effect on the students' sense of competence. Because the staff nurses did not have a role in assigning a grade to the students, their feedback served as evaluation for the looking good as a nurse goal. When the staff accepted the students' presence, helped them willingly, and made them feel like part of the health care team, the students' sense of competence increased.
The students were very clear in their view that there were two separate sets of criteria for evaluating their performance in the clinical setting. Evaluation of student performance by the instructor resulted in a grade. Evaluation of nurse performance focused on the quality of nursing care that the students delivered to their patients. This was primarily self-evaluation based on the kinds of environmental and internal evidence already described.
The grade for the clinical course was the evaluation of their student role. Students perceived that their grade depended on how well they answered the instructor's questions and how well they did with charting and written care plans. As the students felt more competent in their nursing performance, they were able to discount any negative effect of the clinical grade on their goal of looking good as a nurse.
Just as the students clearly had two sets of criteria for evaluating their performance in the clinical area, they had two roles to fill. They were students and they were nurses. They did not occupy both roles at the same time but alternated between the two roles. The currently predominant goal would determine which role the student occupied.
Students described themselves as being in a student role when they were studying outside the clinical setting in such activities as reading, preparation of nursing care plans, and practice in the skills lab. The student role also included much of the student-instructor interaction in which the student was concerned primarily with the goal of looking good as a student. Students developed a repertoire of actions that were intended to increase the probability of looking good as a student in these interactions.
The second role that students assumed in the clinical area was that of nurse. This role was closely associated with the goal of helping the patient and seemed to have a far greater effect on student behavior in the clinical area than did the student role. With the exception of the brief time that the students spent in the presence of the instructor during a clinical practice day, they were in a nurse role. The students tried to organize their approach to the clinical practice environment so that they were in a nurse role when the patient was directly involved and in a student role outside of their nursing care activities.
Within this role structure, learning and looking good as a student were not synonymous. Looking good as a student did not necessarily imply learning. Looking good as a student was a type of self-presentation where it was not so much what you knew that counted, but rather what the teacher thought you knew. Students developed this style of self-presentation during the course of their academic careers and modified it to fit the new expectations of a clinical course. Nursing students discovered that although they were still students and were completing course requirements, they were in a setting where they must try to balance the demands of two roles that might have competing or conflicting requirements.
The students believed that while they were in the clinical practice environment, the nurse role was more important. They might have to relinquish actions directed toward meeting the demands of the student role to meet the demands of the nurse role. Because of the relative importance of the nurse role, students were willing to structure their clinical learning experiences in ways that were threatening to the traditional student role. Asking the questions that were essential if the student was to provide safe, adequate care was not always consistent with presenting a good image as a student.
Looking good as a student involved finding out what the instructor expected and convincing the instructor that those expectations had been achieved. The students' first choice of action was to meet the demands of both roles. Whenever possible, they tried to provide good patient care and to look good as students. One method of achieving this balance was to go to the nursing staff with questions and for supervision of skill performance. Staff observations of students' performance were not perceived to be part of the evaluation of the student as student. The student felt free to be a learner.
The nursing student perspective that shaped the students* learning behavior in the clinical area also included their ideas about the role of the instructor and the staff nurses in the process of student learning. Evaluation was the most frequently mentioned aspect of the instructor's role. The students had the sense that their instructor was always evaluating and, moreover, could remember everything that each student said or did. Several of the students described student-instructor interactions in adversarial terms. These students perceived that they were involved in a contest where the student tried to look good and the instructor tried to make the student look bad. Evaluation was rarely viewed as a formative process that helped the students improve their nursing practice.
In defining the instructor's teaching function, the students frequently compared teaching from the instructor and teaching from the staff nurses (staff nurses had no official responsibility for teaching in this setting). In these comparisons, the instructor was identified with the world of theory and the staff nurse with the real world of clinical practice. Other roles that students identified less frequently for both instructors and staff nurses included protecting the patient, supporting the student, and being a role model.
The nursing student perspective, as defined in this study, is consistent with the premises of symbolic interactionism. Symbolic interactionism is a sociologie theory in which meaning is an outcome of social interaction. Meanings are "social products, creations that are formed in and through the defining activities of people as they interact* (Blumer, 1969, p. 5).
The social context of the clinical setting and the interactions that occurred there among students, instructors, patients, and staff were the basis for the meanings the students assigned to the learning process and to the roles each individual played in this clinical setting. There was a constant interplay between defining the situation (assigning meaning to people, things, and events) and responding to that situation. The nursing student perspective is a summary of the meanings that the students derived from their interactions in this social context. The usefulness of the tenets of symbolic interactionism in this study point to the potential use of this theoretical framework in further research on learning in a clinical setting.
The descriptions of the nursing perspective may serve as a catalyst for clinical instructors to examine their approach to the learner in new ways. Instructors can examine their ideas about the purpose of the clinical practice experience in nursing education. Is clinical practice time for teaching and learning, or is it for evaluation? One of the clearest implications of this study for nurse educators is the necessity to differentiate teaching time from evaluation time, as suggested by Kushnir (1986). If this distinction is not made, the student will view all interaction with the clinical instructor as evaluation. Diekelmann (1992) describee how students who are evaluated for a grade by their teachers may be penalized for learning. Infante's model of clinical teaching (Infante, 1975; Infante, Forbes, Houldin, & Naylor, 1989) is one possible approach to making the clinical learning experience more effective, efficient, and less stressful for the learner, lknner (1990) suggests moving from the traditional power-based model of teaching to a teacher-aslearner who works with students in the model of teacher as midwife (Belenky, Clinchy, Goldberger, & Tarule, 1986)
This study can serve to link what is known about teacher and learner characteristics with educational outcomes. Instructional methodologies that do not take into consideration the effects of the nursing student perspective are not likely to have the anticipated outcomes. The effects of any instructional methodologies on the learning process will be mediated by the nursing student perspective.
- Beck, C. T. (1991). How studente perceive faculty caring: A phenomenological study. Nurse Educator, 16, 18-22.
- Belenky, M.F., Clinchy, B.M., Goldberger, N.R., & Tarule, J.M. (1986). Women's ways of knowing: The development of self, voice, and mind. New York: Basic Books.
- Blumer, H. (1969). Symbolic interactionism: Perspective and method. Englewood Clifis, NJ: Prentice-Hall.
- Diekelmann, N.L. (1992). Learning-as-teeting: A Heideggerian hermeneutical analysis of the lived experiences of students and teachers in nursing. Advances in Nursing Science, 14, 72-83.
- Plagier, S., Loper-Powers, S., & Spitzer, A. (1988X Clinical teaching is more than evaluation alone! Journal of Nursing Education, 27, 342-348.
- Goftman, E. (1967). Interaction ritual: Essays on face-to-face behavior. Garden City, NJ: Doubleday.
- Infante, M.S. (1975). The clinical laboratory in nursing education. New York: Wiley.
- Infante, M.S., Forbes, E.J., Houldin, A.D., & Naylor, M.D. (1989). A clinical teaching project: Examination of a clinical teaching model. Journal of Professional Nursing, 5, 132-139.
- Kleehammer, K., Hart, A.L., & Keck, J.F. (1990). Nursing students* perceptions of anxiety-producing situations in the clinical setting. Journal of Nursing Education, 29, 183-187.
- Knox, J.E., & Mogan, J. (1985). Important clinical teacher behaviors as perceived by university nursing faculty, students and graduates. Journal of Advanced Nursing, 10, 25-30.
- Kushnir, T. (1986). Stress and social facilitation: lhe effects of the presence of an instructor on student nurses' behavior. Journal of Advanced Nursing, 11, 13-19.
- LeCompte, M.C., & Goetz, J.P. (1982). Problems of reliability and validity in ethnographic research. Review of Educational Research, 29, 352-369.
- Lincoln, Y.S., & Guba, E.G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage.
- Melia, K.M. (1982). Tell it as it is" - qualitative methodology and nursing research: Understanding the student nurses' world. Journal of Advanced Nursing, 7, 327-335.
- Olesen, V.L., & Whittaker, E.W. (1968). The silent dialogue: A study in the social psychology of professional socialization. San Francisco: Jossey-Bass.
- O'Shea, H.S., & Parsons, M.K. (1979). Clinical instruction: Effective and ineffective teacher behaviors. Nursing Outlook, 27,411-415.
- Pagano, K.D. (1988). Stresses and threats reported by baccalaureate students in relation to an initial clinical experience. Journal of Nursing Education, 27, 418-424.
- Sandelowski, M. (1986). The problem of rigor in qualitative research. Advances in Nuraing Science, 8, 27-37.
- Spradley, J. (1980). Participant observation. New York: Holt, Rinehart & Winston.
- Tanner, C.A. (1990). Reflections on the curriculum revolution. Journal of Nursing Education, 29, 295-299.
- Theis, E.G. (1988). Nursing students' perspectives of unethical teaching behaviors. Journal of Nursing Education, 27, 102-106.
- Windsor, A. (1987). Nursing students' perceptions of clinical experience. Journal of Nursing Education, 26, 150-154.
- Wong, D. (1978). Nurse-teacher behaviours in the clinical field: Apparent effect on nursing students' learning. Journal of Advanced Nursing, 3, 369-372.