Clinical learning experiences refer to the totality of directed activity in which students engage in nursing practice with consumers to meet health care needs (Haukenes & Mundt, 1983). The major goal of these experiences is to provide opportunities in realistic work settings that permit the nursing student to develop the knowledge, skills and attitudes of a beginning practitioner. The selection of appropriate clinical learning opportunities for the nursing student is acknowledged as a crucial element in the clinical education program (Infante, Forbes, Houldin, & Naylor, 1989; Reilly & Oermann, 1992). Within the structure of these clinical experiences, students practice caring for patients/clients in settings such as hospitals, clinics and homes.
The clinical education of students is experiential in nature, a necessity in a practice discipline such as nursing. The selection of patient or client learning experiences needs to be based on a rational process which follows educational principles (Iwasiw & Goldenburg, 1990). Although authors (Haukenes & Mundt, 1983; Infante, Forbes, Houldin, & Naylor, 1989; Reilly & Oermann, 1992), have addressed the importance of selecting appropriate clinical assignments, limited direction is available for teachers to apply this knowledge.
The purpose of this article is to describe the factors that influence the process of selecting learning experiences in the clinical area with particular reference to senior baccalaureate nursing students in acute care settings.
Learning Experiences in the Practice Setting
Experiences in the clinical setting are not synonymous with a laboratory practicum. It is only in the actual clinical setting that students are socialized into the role of the professional nurse. Part of socialization into the nursing role involves the development of a commitment to be responsible for one's actions. It is in the clinical setting where students can witness the results of their actions and where accountability is demanded (Reilly & Oermann, 1992). In actual practice, students learn to make decisions in constantly changing patient situations, to organize and manage their time, to set appropriate priorities, as well as begin to understand the patient experience. It is difficult to replicate communication with anxious new parents or the care of anguished, uncomfortable human beings in a laboratory setting.
If one sees the clinical area solely as a place to apply theoretical knowledge, then, as educators, we are ignoring the wealth of practical knowledge that is embedded in the actual practice of nursing care in the various clinical settings. Practice has frequently been viewed as a laboratory, rather than as a living situation, imbued with both theoretical and practical knowledge (MacLeod, 1990).
Carpenito and Duespohl (1981) indicate that nurse educators have the responsibility for fostering educational opportunities in the clinical setting that will facilitate the preparation of a beginning practitioner. However, the descriptions of the process of selecting clinical learning experiences are general in nature, and include consideration of such factors as: clinical objectives (Reilly & Oermann 1992), the nature of nursing, health needs of populations and the educational environment (Haukenes & Mundt, 1983), the transfer of learning from classroom to clinical setting, as well as the promotion of decisionmaking skills and an inquiry for further learning.
Goldenberg and Iwasiw (1988) surveyed 54 college and university nursing faculty and reported that the participants considered the criteria of students' individual learning needs, patients' nursing care needs, and matching of patients' needs with students' learning needs as being the most important in patient selection.
Bürge (1990) identified that there is no commonly accepted curriculimi model to enable nurses to synthesize the knowledge and develop the skills to function as educators in baccalaureate programs. However, broad components have been recognized: curriculum development, teaching strategies, principles of evaluation, learning theory, and practice opportunities in teaching.
Earlier, Karuhije (1986) had surveyed American nursing educators (N =211) attending a nursing convention. The majority of respondents (78%) agreed with the following statement: "Most graduate programs do not provide individuals with basic information on clinical instruction.*
Figure. Model for selecting clinical learning experiences.
Due to the recognized need for guidelines pertaining to the clinical selection process, the authors propose that there are four factors that should be considered, namely: curricular goals, learning environment, teaching expertise, and learner characteristics. This article will elaborate on these factors with clinical examples to emphasize their interrelatedness.
Process of Selecting Clinical Learning Experiences
The authors believe that the process of selecting clinical learning experiences warrants the consideration of the educational institution's curricular goals, the learning environments which are best able to meet these goals, the clinical expertise of the teacher, and the students themselves.
The underlying assumption in this article is the interrelatedness of the four factors illustrated in the schematic representation (Figure). The arrows indicate the direction of influence and relationships between the four factors and the process of selecting clinical learning experiences. Although each of the factors will be examined separately, the examples used throughout this article will illustrate how the factors influence one another.
Clinical experiences should be chosen which are consistent with the educational institution's beliefs about the nature of nursing and nursing practice (Haukenes & Mundt, 1983). The curricular frame of reference for this article is an undergraduate baccalaureate degree program.
One of the major goals of any baccalaureate nursing curriculum is the development of decision-making skills in its students. Clinical judgment is defined by Tanner (1987, p. 154) as "a series of decisions made by the nurse in interaction with the client regarding (1) the type of observations to be made in the client situation, (2) the evaluation of the data observed and derivation of meaning (diagnosis), and (3) nursing actions that should be taken with or on behalf of the client (management).* Students need substantial practice opportunities so that they can be skilled in weighing data and selecting appropriate goals and interventions. Caring for patients in different contexts requires that students may need to reorder the internal structure, for example, of a clinical problem calling for very different nursing assessments and interventions (Benner, 1984; Carnevali, Mitchell, Woods, & Tanner, 1984).
Another goal of baccalaureate education is the development of a scientific basis for nursing care. Thus, the clinical teacher should provide opportunities that encourage the student to build on and apply previous knowledge. When caring for an elderly, confused patient, for example, it is important for the student to know the relationship between the confusion state and drug interactions, electrolyte imbalances, oxygen levels, pain and/or previous patterns of functioning for that patient. In the classroom setting, students learn that it is important to turn the patient with mobility problems every 2 hours to prevent alterations in skin integrity. However, it is only in the clinical setting that students apply this knowledge so that it takes on meaning. By caring for many patients, students understand when to turn patients, how to turn them, and who is at highest risk for pressure sores. Learners need repeated experiences observing patients in various situations in order to apply knowledge in changing circumstances (Infante, 1985).
Another major goal of any nursing curriculum is the development of caring behaviors. By interacting with patients, students gain a deeper understanding of the patient's perspective. For example, nursing students can be assigned to care for patients who have chronic illnesses and have adapted their life accordingly. The goal of this experience is to facilitate students in developing an understanding of the challenges in daily living that face someone with a chronic illness, as well as to provide an Dpportunity to reflect on the unique contribution that nursing can make to this patient and family.
In their everyday work world, nurses live out the development and extension of knowledge (Benner, 1984). If one regards the clinical setting as being imbued with knowledge, then through the selection of clinical learning experiences, students can be encouraged to explore questions about what it means to nurse and be nursed. For example, in the provision of care, hour by hour, students are able to witness the impact of their interventions, reassess client status, and develop further inferences and interventions. Through repeated exposure to a variety of patients, nursing students learn to select the most appropriate interventions for a particular patient situation.
The learning environment selected for students' clinical experiences is specified by the curriculum model. In a curriculum which moves from simple to complex, the objectives for a clinical course in the more senior years would focus on health problems with multiple stressors, and the clinical setting might be a large teaching hospital. Today, the learning environment in an acute care setting is composed of high patient acuity, increased technology, multiple health professionals, and financial restraint on staffing resources. All of these variables must be considered when selecting learning assignments. For example, the care of patients on some nursing units would mandate that students be able to cope with sudden and unexpected changes in patient status, as well as family concerns regarding the prognosis. These learning environments are best suited for senior students. It is imperative that clinical teachers be available to guide students as they learn to problem solve in these complex patient situations. Students on these units are also caring for patients who frequently are experiencing an acute episode of a chronic health problem. Selection of clinical experiences such as this can help the student to understand and plan the ambulatory care and home needs of the client and the family in addition to the short-term treatment for this episodic event.
Nursing staff working in the learning environment play an important role in the selection of clinical learning experiences. Nursing staff have an in-depth knowledge of the patients and the ward environment. Therefore, supportive clinical staff can facilitate the process by informing the teacher of patient situations that might provide valuable learning experiences. When the clinical professor is familiar with the hospital staff and the clinical unit, the student experience is maximized. This is best achieved when clinical professors are allowed to return to the same units for consecutive years. This strategy allows an effective working relationship to develop, and expectations of all parties concerned are clear.
One of the ways students learn the nursing role is through observation of their teacher providing nursing care in specific patient situations. Therefore, teachers must have nursing experiences relevant to the clinical learning environment selected in order to be able to serve as a professional role model. Teachers are required, for example, to articulate the thinking processes used in assessing patients.
Shulman (1986) describes three categories of content knowledge essential for teaching: (1) subject matter content knowledge, (2) pedagogical content knowledge, and (3) curricular content knowledge.
Subject matter knowledge refers to the teacher's knowledge of the truths and theories of a specific domain and approaches to teaching that content. In nursing, for example, subject matter content knowledge includes the content that defines the nursing role and approaches to patient care that exists within each nursing specialty. A deep understanding of subject matter knowledge enables the clinical teacher to develop, as well as assess, essential nursing knowledge in students.
The clinical instructor must select patient assignments that will challenge, but not overwhelm each student. The assignments must be within the constraints of what can be monitored by the teacher and ensure patient safety at all times. Only the teacher with a strong clinical background can determine which patients have conditions and situations that are appropriate for the students' competency level. As well, the additive effect of each student caring for 2 to 3 patients each (for a possible total of 24 patients) means that a highly knowledgeable and skilled clinical teacher is essential to safely monitor both students and patients. In some clinical assignments, selected students are given a lighter assignment one week, while the other members in the group have more complex patients. Then, the following week, the situation reverses. This allows the clinical teacher to manage the situation when several potential crises are operative.
The nursing educator must also possess pedagogical content knowledge and apply this knowledge to the unique demands of the clinical learning environment. For example, the clinical teacher must be aware of the individual learning needs of each student and select clinical learning opportunities which will facilitate student growth.
The third category, curricular content knowledge, refers to the instructional resources available to the teacher and how they can be incorporated to promote learning in the clinical setting. The clinical teacher must be familiar with available resources such as equipment, publications and personnel that can be used in the clinical course. The teacher must also know the content being studied in accompanying theoretical nursing courses, which Shulman (1986) calls lateral curricular knowledge. This knowledge is essential for planning effective learning experiences that allow the students to apply what they are learning in theory courses. IC for example, the topic in the theory course that week is care of patients with cardiovascular problems, then the clinical teacher would try to select patients with related health conditions so that the students transfer the knowledge gained in the theory course to planning and implementing patient care interventions in the real world. Placing learning in a functional context encourages the application of different forms of knowledge and the understanding of various concepts in such a way as to clarify pertinent factors and their interaction and interconnectedness (Heliker, 1994).
Lateral curricular knowledge allows the nursing teacher to plan clinical learning experiences that build and reinforce the content of concurrent courses, such as ethical issues, so that other courses and how these are reflected upon in the practice setting in particular patient situations.
It is also important that the clinical teacher know what has been taught in previous clinical courses and what will be taught in future courses to provide continuity to the students' clinical progress. Vertical curricular knowledge (Shulman, 1986), or awareness of the sequencing of learning experiences from year to year, enables the clinical teacher to plan learning opportunities at the appropriate level for the students' abilities. The clinical teacher in the third year of a nursing program must know what knowledge and skills the students encountered in the first and second year in order to ensure a continual progression in the students learning.
The clinical experience allows the students to practice both the art and science of nursing. However, this setting can, at times, be anxiety provoking due to the unpredictable nature of patient situations as well as the many psychosocial problems that patients and families must face (Pagana, 1988). Clinical teachers must know when and how to provide the support and encouragement to help students develop confidence in their ability to nurse. In the selection of clinical assignments, an attempt is made to match the student's ability with the patient situation (complexity of care, special needs, linguistic and cultural requirements). Thoughtful attention to the matching of student and patient assignment results in learning experiences that foster the development of an identity as a competent beginning nurse (Loving, 1993).
Learner characteristics will be discussed under the broad headings of application of knowledge, development of psychomotor skills, clinical judgment skills, and professional identity.
Application of Knowledge
As students progress through a nursing program, theii learning needs change. A sequence of experiences that hat both continuity and connection is important. As the clinical experience continues, the clinical assignment should provide for progressive development of the student The assignment should be based on specific clinica objectives and reflect the learner's needs and abilities. The student should understand the rationale for the clients selected so as to emphasize the relationship between s particular experience and intended learning outcomes.
The more extensive the student's knowledge base, thd more likely the student will be able to select data that ii pertinent to decision making (Tanner, 1987). It follows then that students in their senior year can make decisions when unexpected events occur, such as a change in th« patient's level of consciousness. In contrast, patients who] have multiple problems requiring complex nursing strategies would not be selected for beginning students due to their limited repertoire of knowledge and skills. Extensive clinical knowledge and experience allows the teacher to select assignments appropriate to the level of the student Inappropriate patient selection could jeopardize patient safety, as well as produce a frustrating experience for the student.
Each student's overall ability to confidently and consistently provide safe, competent care in an organized manner is a major consideration when selecting an individual patient assignment. An extremely competent student who benefits from being challenged will be given a more complex patient assignment. On the other hand, an anxious student who lacks confidence and has difficulty adapting to unexpected changes initially will require less complex, more predictable experiences with opportunities for frequent contact with the instructor. Once confidence develops, then this student can be assigned patient situations comparable to other students at this level.
The instructor monitors the variety and number of specific nursing experiences provided to each student. To ensure that the students have the psychomotor skills expected of beginning practitioners, a checklist of specific nursing procedures is updated regularly by the clinical teacher and student (Shellenbarger, 1991). This checklist includes not only items such as surgical dressings, but also skills such as patient teaching. The teacher refers to this checklist and should also consider specific preferences communicated by the students when selecting the patient assignment. For example, a student may request additional experience with a particular patient to be able to further develop the nurse-patient relationship. These requests are accommodated, when possible, if it is beneficial to both the patient and the student.
Clinical Judgment Skills
First year nursing students as novices need content patient care in the form of rules to safely enter new situations (Benner, 1984). For instance, they need to know the range of a normal blood pressure so that they are aware of changes which would be considered significant. However, as students progress, the teacher helps them to focus not only on noting the change in the patient's blood pressure, but also understanding the implications of changes, that is, making a clinical judgment. Through clinical experiences, the students realize that the rules they applied so stringently are really guidelines. Thus, they are able to make decisions with many interacting variables and constantly changing circumstances. The clinical teacher must provide learning experiences that allow students to build on past experiences to guide the interventions so that the nursing care becomes situation specific.
Socialization to the profession of nursing is a process by which the student develops an identity with the profession by internalizing the norms, values, knowledge, skills, and behaviors necessary to practice that profession (American Association of Colleges of Nursing, 1986). In the clinical setting, students experience their most intense professional socialization. This is where they are exposed to the requirements of deadlines, interacting with other health professionals, reflecting on the unique contribution of nursing to patient care and the health care system in general. Through organized, structured and selected learning experiences, students develop the confidence in their abilities to provide patient care. As this confidence is developed, students are able to focus their attention on the myriad of factors affecting the work and life of nurses, such as the impact of technology as well as ethical and legal issues.
Through the analysis of personal experiences as clinical teachers, the authors have proposed four factors that should be addressed when selecting clinical learning experiences. The factors include curricular goals, learning environment, teacher expertise, and learner characteristics. The ways in which each factor influences the other factors, as well as the impact on the selection process, was explored. It is hoped that this article will generate further inquiry into the complex process of selecting clinical learning assignments.
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