Nursing is a practice-based discipline that engages students in developing not only the theoretical knowledge on which to base client care, but also the practical application skills required to implement that knowledge. Opportunities to develop these fundamental skills are provided through clinical education placements in off-campus health service settings. Clinical education is considered to be a vital component of university undergraduate nursing curriculum and is the subject of a growing body of academic literature.
Research has shown that a number of interrelated factors affect the outcomes of clinical education (Nursing Education in Australian Universities, 1994; hereafter referred to as the Reid Report). On the one hand are factors associated with the quantity and type of clinical education provided to students. Within Australia these factors vary according to state or territory registration requirements and the curricula and resources of the different schools of nursing. On the other hand are qualitative factors, which include the organization of clinical education and the relationships between participants, such as clinical facilitators,* nursing staff, and students (Reid Report, 1994). While quantitative and qualitative factors both surely contribute to graduate competence, research such as that carried out by Battersby and Hemmings (1991) has highlighted the importance of the quality of the experience.
Quality however, is a nebulous concept at best; it is elusive and difficult to define, much less evaluate. Current value systems, knowledge, and expertise influence beliefs about quality, and value judgments of quality can differ greatly among the constituencies assessing it (Kitson, 1986; Koch, 1992). Judgment or evaluation is to a large extent a natural and ubiquitous part of life; people base their day-to-day choices and decisions on their perception of the nature and worth of something. Evaluation is an "ever-present aspect of considered action [and is] present in a range of individual and public judgment processes" (Kemmis, 1986, p. 118). It is likely therefore, that not only are judgments about the nature and worth of clinical education made by all who have a stake in the eventual outcome, but also that there will be a difference in the perceived quality of the components of clinical education.
According to the Reid Report (1994, p. 207) "there is usually more than one view of what constitutes good clinical education, if only because there is more than one view of what constitutes good nursing practice." Those who are likely to have a view of what constitutes good clinical education include university nursing faculty, clinical facilitators, health service employers, clinical nursing staff, nurse registration bodies, the clients, and the students. Consideration of the concerns, issues, and valueperspectives of all the stakeholders promotes a better understanding of a situation and thus leads to more effective and appropriate decisions about quality (Guba & Lincoln, 1981; Kemmis, 1986; Stake, 1975/1988). However, the views or natural evaluation processes of stakeholders other than university nursing faculty generally have little impact on curriculum decision-making regarding clinical nurse education.
As with many words in the English language, the term "curriculum" means different things not only to different people, but also within different contexts. Within the context of this study a broad and inclusive view of curriculum is held, with curriculum being understood as "a praxis, a dynamic interplay of theoretical concepts and professional work within a critically reflective mind set" (Macpherson, 1994, p. 53). The term "curriculum making" is adopted throughout the paper to indicate the inclusion of the many components of curriculum, such as planning, implementation, and ongoing review. According to Lovat and Smith (1995):
Curriculum is more than a set of definitions. It can best be conceived as decision-making action that integrates both intention and the manner in which the intention becomes operationalized into classroom reality. This reality, however, must be negotiated and modified because of a range of contextual circumstances (p. 23, emphasis added).
Essentially, the intention, or the aim of nurse education is to produce a competent practitioner, "thus protecting the general public from incompetence and maintaining professional standards" (Lafferty, 1997, p. 281). As stated earlier, clinical education placements in off-campus health service settings provide learning opportunities for students to not only further develop their knowledge and skills, but to also "acquire the kinds of professional and personal skills, attitudes and values thought essential for entering the health care system" (Wong & Wong, 1987, p. 505). Thus, for students of nursing, the reality in which the intention becomes operationalized includes not only the university classroom but also the clinical setting. By association, those involved in the process of curriculum making, that is to say, those who are involved in "decisionmaking and choosing between alternatives" (Lovat & Smith, 1995, p. 24) include not only university nursing faculty (academic nurse educators), but also others, such as clinical facilitators, clinical nursing staff, and students. However, the curriculum-making that occurs within the context of the clinical setting is seldom recognized much less utilized. As already discussed, these stakeholders are generally not invited to even share their views, much less invited to participate in curriculum decision-making regarding clinical nurse education.
Traditionally, university nursing faculty make the decisions about all aspects of the clinical education curriculum. Reference to the views of students or other interested parties has been minimal (Playle, 1995), and such representation has had little impact on either the nature, the design, or the delivery of the curriculum (Booth, 1992). Academics "are as reluctant as other professionals to acknowledge the cogency of outsider judgments" (O'Neill & Meek, 1994, p. 93). It is unrealistic and arrogant to presume that because they possess the occupational arcana, academics alone can legitimately judge the worth of profession-specific actions and are the most capable to make all decisions that affect learning.
Contemporary thinking about the nature and purpose of teaching and education and about teaching and learning, not only recognizes that the pedagogical relationship does not need to be top-down for significant learning to occur, it also recognizes that adult learners do better with less direction and more participation (Knowles, 1990). Such reasoning conjures an image of students as active participants, not as passive recipients or empty vessels waiting to be filled. "The corollary of having students as active participants in the construction of learning is that learning becomes meaningful (Grundy, 1987, p. 102). At the heart of these conceptual changes lies student centeredness, a concept which, within the context of curriculum making, means that "courses will focus on, and be committed to, the involvement of students at all stages of the process" (Playle, 1995, p. 219).
The construction of the curriculum by both teachers and students in partnership has been termed "negotiating the curriculum" (Boomer, 1982). The idea of a negotiated curriculum does not imply the abdication of responsibility for curriculum-making by academic staff, nor does it mean giving students, or any other group "carte blanche" to make decisions. Rather, "curriculum-negotiation involves giving students a voice in the choice and development of learning opportunities: both the 'what' and the *how' of curriculum" (Carr & Kemmis, 1986, p. 171). The concept is especially consistent with democratic principles and notions such as consultation, collaboration, and social justice. There are many reasons why the input of students could contribute to a more effective and mutually satisfying curriculum. For example, many of the anxieties, concerns, and issues faced by today's universitybased student of nursing may have been forgotten or never experienced by some academic nurse educators. Arguably, when curriculum decisions are based on the needs of students as perceived by students or "tempered with humane values rather than narrowly technocratic or bureaucratic concerns" (Kemmis, 1986, p. 118) the decisions are likely to be more effective and appropriate. Essentially, this can be seen as an argument for curriculum-making based on responsive evaluation.
Responsive evaluation is based on "what people do naturally to evaluate things, they observe and react ... it orients more directly to program activities than to program intents" (Stake 1975/1988, p. 145). Of central importance to Stake's Responsive Evaluation Model is responsiveness to audience requirements for information, and reference to the different stakeholder value-perspectives in reporting the success and failure of the program. The purpose of this paper is to report on a responsive evaluation study, which was carried out within a university school of nursing. The aim of the study was to evaluate the clinical experience in a psychiatric setting from a student perspective and by doing so generate information that would lead to more effective and mutually satisfying nurse clinical education.
While nurse clinical education is the subject of a growing body of academic literature, there is little research that uses students' perceptions. Studies using students' perceptions of their learning experience (e.g., Cooke, 1996; Dunn & Hansford, 1997; Hart & Rotem, 1990, 1994; Kanitsaki & Sellick, 1987; Knox & Morgan, 1985; Morgan & Knox, 1987; Strahan & Thornton, 1995; Windsor, 1987; Wiseman, 1994) have largely concentrated on exploring and describing the personality characteristics and behaviors relating to effective clinical teaching. Only a few studies using students' perceptions have been carried out in an Australian setting and, with few exceptions, are relative to the general hospital context.
One exception is a study by Strahan and Thornton (1995) that explored student perceptions of their peers and their facilitators "to uncover some of the student perceptions of the strengths and shortcomings of the [psychiatric] clinical placement program" (p. 43). The present study can be seen as an extension of the work by Strahan and Thornton. Other studies that especially informed this project were those of Hart and Rotem (1994) who, as a result of an exploratory study of students' perceptions, were able to conclude that the culture of the agency, and a positive relationship between student and agency staff, were crucial factors in detennining the outcome of clinical practice. Cooke (1996) examined students' perceptions of difficult and challenging clinical situations and concluded that effective teaching strategies used by the clinical facilitator were pivotal in addressing the issues. Dunn and Hansford (1997) investigated the factors influencing students' perceptions of their clinical learning environment. They found that the development of a positive learning environment was largely dependent on the interpersonal relationships between the participants. Essentially, the findings of these three studies supported that of Battersby and Hemmings (1991) concerning the importance of the quality of the experience to the outcomes of nurse education, especially in the quality of the relationships between participants such as students, facilitators, and agency staff. Given the centrality of these three sets of participants to clinical education, it was decided to use them, along with the notion of quality, as an organizational framework to guide the study.
Question, Context, Participante
This study, which advocates student voice in curriculum decision-making, was directed by the question: From the students' perspective, what constitutes a quality clinical learning experience in a psychiatric context, and how do facilitators, clinical nursing staff, and students contribute to that quality? The study was conducted at a large, university-based, school of nursing in Brisbane, Australia, towards the end of the second semester, 1997. The 117 respondents, from a possible 377, were in the second year of the three-year undergraduate nurse education degree program. They had all completed an 80hour clinical practicum in a psychiatric setting, plus a 40hour clinical practicum in other settings where the focus was on psychosocial issues that threaten mental health integrity.
Information-Gathering Strategies and Procedures
A self-administered questionnaire was constructed around the concept of quality in relation to clinical practice, with special reference to the quality of the relationships between students, facilitators, and clinical nursing staff. The observation that students generally talk about their clinical experience in terms of a "good" or a "bad" "prac" directed the wording of the questionnaire. The deliberate use of the naturalistic style of student "corridor talk" (Rabinow, 1986) in wording the questionnaire was intended to encourage the voicing of student concerns about the psychiatric clinical education curriculum. It was also meant to reinforce the new, more equitable relationship between teacher and learner that the study upholds. Students were invited to respond to eight openended questions:
* In your view what is a "good" prac in the psychiatric setting?
* In your view what is a "bad" prac in the psychiatric setting?
* Please describe what I how you contribute to ensuring a "good" psychiatric clinical prac?
* Please describe what I how your clinical facilitator contributes to ensuring a "good" psychiatric clinical prac?
* Please describe what I how the clinical nursing staff contribute to a "good" psychiatric clinical prac?
* Please describe what I how you may have contributed to a "bad" psychiatric clinical prac?
* Please describe what /how your clinical facilitator may have contributed to a "bad" psychiatric clinical prac?
* Please describe what /how the clinical nursing staff may have contributed to a "bad" psychiatric clinical prac?
While these questions were structured to promote response to four predetermined categories (clinical practice, clinical nursing staff, clinical facilitators, and students), the framework had no restrictions or limitations on the feedback that could be given. This strategy was intended to indicate not only a valuing of student experience, but also a true desire for student feedback. Asking for responses to each of the four categories of both strengths and shortcomings (i.e., "good" and "bad") was a strategy aimed at capturing as many perceptions as possible and thus providing optimal insight into aspects of the students' subjective world.
The responses were recorded on a self-administered questionnaire, which was distributed toward the end of a large group lecture. Students were given about 20 minutes to reflect on their experiences and return a written response. Anonymity and confidentiality were assured and the voluntary nature of participation emphasized. All required ethical standards were met. The gathered information was subjected to descriptive analysis to organize it for further examination and interpretation.
The collected responses were searched for emerging concepts, themes, or issues and these were distinguished with highlighter pen on the response form. Essentially, the themes were inductively derived from the data using "paradigmatic reasoning" (e.g., Bruner, 1986; Polkinghorne, 1995). Each of the four categories was analyzed independently of the others. No attempt was made to analyze difference or relationship between perceived strengths or shortcomings in any category. Rather, the good and the bad aspects of each category were integrated to form composite pictures of what makes a quality clinical experience and the ways in which the students, the facilitator, and the clinical nursing staff contribute.
The identified themes or issues for each category were then organized into clusters and assigned a number. The assigned number was inserted onto the response form beside the response that corresponded to the cluster. (Essentially, this manner of organizing the unstructured data is a modification of content analysis methods well described by, for example, Burns, 1994; Field & Morse, 1985; Miles & Huberman, 1984). Finally, to provide a visual representation of the information concerning the four categories, the clusters from each category were organized into frequency distributions. Themes, which were identified by less than 10% of respondents, were arbitrarily organized into a miscellaneous cluster. Please note that all the participants did not respond to all categories.
Each of the four categories is introduced separately. The constructed frequency distribution is presented first. Although the clusters of themes within each of the four categories are presented in hierarchical format, this is done for convenience and ease of interpretation. Ranking provides a useful way of presenting the data; it does not indicate level of importance. Each response from each participant has significance for someone. Each cluster is briefly described and illustrated with a compilation of excerpts transcribed from the responses. By using the natural language of the students' own terms, it is hoped a vicarious experience for the reader will be generated.
Quality Clinical Practice Experience (n = 117)
The themes identified in this category were organized into six clusters: (1) Opportunity to learn, 62 (53%); (2) Clinical nursing staff, 50 (43%); (3) Involvement, interaction or participation, 47 (40%); (4) Organization/administration issues, 39 (33%); (5) The clinical facilitator, 28 (24%); and (6) Ambience or prevailing atmosphere, 19 (16%).
The opportunity to learn was claimed by 62 (53%) of the respondents to be a contributing factor to the quality of clinical practice. The nature of these opportunities essentially differed between those who wanted a variety of different learning experiences, and those who wanted "hands-on" or experiential learning opportunities. When you experience a variety of encounters and you can learnwhere everything you participate in is used to provide you with greater understanding -exposed to various situations. [It is bad] where you see nothing and learn very little, and are unable to physically participate in anything.
The clinical nursing staff as important factors was identified by 50 (43%) of the respondents. A positive attitude toward students, and friendly and helpful guidance were recurring themes. Openness and willingness of staff members to accept students - where staffare friendly and helpful and interact with the students and involve them in things on the ward- who will help and give you tasks to accomplish - being buddied up with decent RNs -ones happy to accept university students.
Of the respondents, 47 (40%) claimed that involvement, interaction, or participation in patient care and other ward activities contributed to the quality of the clinical experience: When you participate as much as possible-have a chance to interact with clients - being involved with interventions and assessments- you feel involved in both the nursing and patient relationships - able to have maximum patient contact.
Organization/administration issues were considered to be factors that contributed to the quality of the clinical practice by 39 respondents (33%). There were four recurring themes in this cluster. (1) Preparation for the practicum: Having an effective introduction /orientation to the setting, including terminology, pharmacology, and how to observe behaviors prior to entering the setting. Tutorials could be a useful tool, e.g., 3 weeks prior to prac. [It is badi when you go out totally unprepared and have got no idea what it is you need to achieve. (2) The structure of the practicum: Perhaps a handbook of "things to be accomplished." [It is bad] not knowing what you are supposed to be doing. (3) Duration of the practicum: A prac that is longer than two weeks. A one-week prac. two weeks is too long. (4) Setting for the practicum: Exposure to acute mental illness -placements which deal with psychiatric conditions fully and professionally.
The clinical facilitator was perceived as being a contributing factor by 28 respondents (24%): A facilitator who cares about what you are doing but is not too strictwhen the facilitator is really excited about teaching and willing to impart knowledge. Having a facilitator who understands that it may be scary etc. 1st time. [It is bad] when the facilitator has no idea what is going on, or what the students are to do or gain from the experience and where the facilitator [and staff] don't give a damn what the students do or learn from the experience, nor are supportive. [It is bad] not being around enough- needs to be around a lot and discuss more.
The importance of the ambience or the prevailing atmosphere of the setting as a contributing factor to the quality of the clinical experience was identified by 19 respondents (16%); 4 respondents emphasized a therapeutic environment and 15 stressed a comfortable, supportive milieu. Where you feel comfortable within a day or two- a supportive environment - where patients feel happy about consulting staff and staff can feel happy about talking to visitors and patients- [It is bad] where patients feel sedated and rejected and staff only enhance this feeling.
Contributions by Students (n = 111)
Six clusters were organized from the themes identified in this category: (1) Finding own learning opportunities, 89 (80%); (2) A positive attitude, 42 (38%); (3) Improving their own knowledge base, 34 (31%); (4) An open mind, 19 (17%); (5) Overcoming personal fears or anxieties, 13 (12%); and (6) Miscellaneous, 10 (10%).
Finding their own learning opportunities and accepting all that were offered was perceived to be an important student contribution to the quality of the clinical experience by 89 respondents (80%). Recurring themes in this cluster centered on taking the initiative and being assertive. / look and ask for experiences when I am prac. I don't wait until something might come up. I look at what the subject has been dealing with over the semester and then try and relate that to my prac- ask lots of questions, make an effort to look for things to do, ways to learn - make opportunities for yourself- be assertive- Fm not assertive enough and thus probably did not utilize all the opportunities -actively seek things to do and ask to see things- to get anything out of it you must put in some effort yourself.
A positive attitude and enthusiasm, and an eagerness and willingness to learn as an important student contribution were identified by 42 (38%) respondents. Start with a good attitude, not the "this is a waste of time" attitude. Be outwardly open and friendly - be eager to learn and see what actually happens - if you are not interested you get nothing out of it - be enthusiastic and offer to help and be willing to do anything.
The importance of improving their knowledge base by preparing cognitively before and during the practicum, by reading up on various mental health disorders and issues, and by generally reflecting on and about aspects of their experience were identified by 34 (31%) respondents. Be prepared by reading up and having a knowledge base about mental health- at the end of each day look up new info - do a bit of personal research - re fleet on my actions- keep a daily journal. By not doing as much research I reading as I could have in relation to the setting, patients, conditions, medications, procedures, etc., I feel if I had more knowledge in what I was seeing and doing I would have had a better and more productive prac.
Having an open mind was considered by 19 (17%) respondents, in the sense of being nonjudgmental and overcoming stereotypical preconceptions about people with mental illness, an important contribution: Approach prac with a positive and open mind- don't jump to conclusions-avoid stereotypical ideas. I think a lot of students hear too many horror stories of psych hospitals and have preconceived ideas- if this could be overcome students would be less intimidated and approach patients and talk with them.
Themes associated with students overcoming personal fears or anxieties were identified as an important contribution by 13 respondents (12%). Preparation may include examining personal fears and biases- put aside the initial fear and understand that they are people like everyone else- [It is bad when] you get nervous, scared and insecure. I was terrified at first but I finished up enjoying it.
The sixth cluster contained miscellaneous themes that centered around recognizing their own limits (2%), not getting emotionally involved (2%), and working as a team (5%).
Contributions by Clinical Facilitator (n = 112)
The themes identified in this category were often closely related but were eventually organized into eight clusters: (1) Sharing of knowledge and experience, 53 (47%); (2) Positive attitude towards students and learning, 50 (45%); (3) Provision of learning experiences, 49 (44%); (4) Availability or presence, 33 (39%); (5) Promotion and maintenance of a positive learning environment, 28 (25%); (6) Debrief or tutorial sessions, 22 (20%); (7) Responsive to student concerns, fears, or anxieties, 14 (12%); and (8) Miscellaneous, 12 (11%).
According to 53 respondents (47%), the facilitator contributed to the clinical learning experience by sharing knowledge and experience. By enjoying the field and wanting to impart knowledge- should be knowledgeable and educational- discuss and work through our knowledge base with us- explains and gives information- gives information to you and answers concerns.
A contributing factor identified by 50 (45%) respondents was a positive attitude toward students and learning. Themes associated with this cluster were mainly concerned with the facilitator's personal characteristics such as being supportive, listening to students, seeing students as individuals, and being enthusiastic and interested. Generating a relaxed and calm relationship with students-helping students feel less pressured- don't just generalize that students are all the same -allow us to express concerns- ask how we are going- make us feel more relaxed and erase the stigma and stereotypes- provide assurance and support- show interest in our learning-doesn't make me feel dumb - is out-going, enthusiastic, and has a sense of humor.
The provision of learning experiences as a valued contribution by the facilitator was identified by 49 (44%) respondents. Associated themes included actively encouraging student participation and interaction by guiding or helping, and role modeling. Participating with students i.e. leading by example- guiding activities- setting tasks each day- ensuring we have the opportunity to experience a variety of situations -organizing as much clinical exposure as possible- allows /encourages us to participate and experience a variety of experiences.
The availability or presence of the facilitator was identified as an important contributing factor to a quality clinical learning experience by 33 respondents (29%). Being there when needed, being available to discuss any concerns and improve our effectiveness- I don't know how she assessed me, she didn't see any of my work. When a facilitator can't be contacted it is a problem and annoys the nursing staff.
There were 28 respondents (25%) who indicated that the promotion and maintenance of a positive learning environment by the facilitator was an important contribution. Themes associated with this cluster were mainly concerned with instructional characteristics such as being visible but not intrusive, providing ongoing and constructive feedback, aware of unit objectives and level of student learning and communicating this to the staff, good interpersonal skills, and good rapport with students and staff. Facilitates meeting objectives through communication with the staff- able to liaise with staff about learning needs and make sure we meet those needs- allows you to be independent but there if needed- keeps an eye on you- provides feedback and maintains a warm and friendly environment.
The provision of either debriefs or tutorials was considered an important contribution by 22 respondents (20%). Giving "mini lectures" every afternoon on specific topics- teach things in the debriefing- make debriefing a learning exercise- debriefing and telling you how you could have done something better -daily tutorials conducted by the facilitator on different topics is an excellent idea - we needed to unwind after each day.
Being responsive to student concerns, fears, or anxieties as an important contribution was identified by 14 respondents (12%). Themes in this cluster included being empathie and understanding of the perceived stress associated with psychiatric placements. Understand that most students have never been in contact with psychiatrically ill patients- not pushing students in certain areas if they feel uncomfortable because they actually do not know what to do, how to act or how to cope- [It is bad when] we are thrown into the deep end if we are not comfortable with it.
The eighth cluster contained miscellaneous themes that centered on professional behavior (6%) and orientation or introduction to the clinical setting (5%).
Contributions by Clinical Nursing Staff (n = 116)
Seven clusters were organized from the themes identified in this category: (1) Attitude toward students, 83 (71%); (2) Open to discussion, 65 (55%); (3) Involve students in direct patient care, 60 (52%); (4) Awareness of students', knowledge base, learning needs, expectations, 20 (17%); (5) Appropriate professionalism, 19 (16%); (6) Role modeling or demonstrating, 11 (9%); and (7) Miscellaneous, 6 (5%).
The attitude toward students held by the clinical nursing staff was a contributing factor to the quality of the clinical experience by 83 respondents (71%). The desired attitude was variously expressed but centered on personal and behavioral characteristics such as showing positive regard for students and being friendly and approachable. Identify students as a resource not a liability- showing interest in students - understanding that the psych, setting is daunting and not making it worse by ignoring us - treating you with respect as a person - helping when you need it- accepting students and university practices - being open-minded to us as students -realizing that they would have been in the same situation when they were in training.
It was considered by 65 (55%) that the disposition of the staff to be open to discussion about aspects of clinical practice was a contributing factor to the quality of the clinical experience. This cluster included themes associated with fairness and listening to student views as well as being informative and offering suggestions. Be fair, be open to see and hear our views- explain what and why they did I said the things they did- and giving us the full benefit of their experience. Being informative and offering suggestions and advice on what to do all day- what patients would be interesting and safe and who was not having a good day. Talking to the students- explain what they do- explain psych, nursing and the sort of roles a psych, nurse takes on.
The inclination of the clinical nursing staff to involve students in direct patient care was considered by 66 respondents (52%) to be a contributing factor to the quality of the clinical experience, and 18 students wanted the clinical nursing staff to be directive and actively provide learning experiences. Going and getting the students when there is something of interest which a student may perform - impart information without being asked; we don't always know what to ask- keep asking us to do things- provide opportunities to increase knowledge. Seemingly, 42 students wanted to be allowed to do things. Be willing to let the students "do" things so we can learn - allow the students to do things. Make an effort to include us in patient activities- allow students to practice what they have learnt.
The clinical nursing staffs awareness of students' knowledge base, learning needs, and expectations was considered an important contributing factor by 20 respondents (17%). Understand that we are there to learn and not purely an annoyance that they can get to do the menial tasks they can't be bothered to do- those who did help us were fairly new graduates [who] are excellent and motivated and eager to share knowledge. [It is bad] treating the students as not knowing anything and thinking that it is beyond the students' knowledge.
Appropriate professionalism became the cluster that subsumed themes concerning what the students perceived as professional behavior from registered nurses. This cluster was identified by 19 respondents (16%) as an important determinant of the quality of their clinical experience. Some of the staff had bad attitudes to the people [in the setting] and those who were suffering from a mental illness- displaying poor nursing care- whining about their workplace -criticized to other students about other students' performance- sitting on their backsides in the office without ever talking to their patients - if we are to follow their example [this] is not conducive to making good MH nurses.
There were 11 respondents (9%) who claimed that the clinical nursing staff contributed to the quality of a clinical practice by role modeling or demonstrating how something should be done. We are there- therefore [they] have a duty to teach us as much as possible- let us follow them around and see how they do things. [It was bad] when they did not allow us to observe them carrying out their role before we were expected to do it. [It was bad] not taking time to walk us through procedures.
There also were 6 responses (5%) that were unable to be subsumed under any common cluster other than miscellaneous, and included themes related to liaising with the facilitator about learning needs, providing constructive feedback, and giving a "handover," or briefing on client status, that neophytes could clearly understand.
The students who participated in this study clearly considered that the purpose of a clinical practicum was to extend through experiential learning what they had been taught in the classroom or university laboratory. They wanted opportunities to learn, to be involved, and to participate actively in direct, day-to-day care of patients. Although they desired access to patient records and other learning resources, they saw this as an adjunct to the experiential learning that a "good" clinical practicum would offer them.
The opportunity to learn, to be involved, and to participate in direct, day-to-day care of patients were persistent themes across all four categories. While the provision or identification of learning opportunities by the facilitator or clinical nursing staff was seen to be a valuable contribution to the quality of the clinical experience, it is noteworthy that the vast majority of respondents (80%) thought that finding and maximizing learning opportunities was something the student should be doing.
A related cluster of themes was the importance of students taking responsibility for improving their own knowledge base. This cluster centered around the perceived need to cognitively prepare before and during the clinical practicum, and included themes such as revising mental health lectures, reading or researching unclear issues or concerns, and reflecting on practice. The themes from both these clusters suggest that the students who participated recognized that they could, and should, take some control of their own learning. The themes also suggest that they want to take responsibility; that they see themselves as active, rather than passive participants in their own learning.
The attitude held toward students by both clinical nursing staff and facilitators was seen by the respondents as being a significantly influential factor on the quality of the clinical experience. Without a positive attitude toward students and learning it is probable that other perceived contributions by these two participating stakeholders could not or would not have occurred. Contributions such as promoting and maintaining a positive learning environment and a comfortable and supportive milieu, being open to discussion, sharing knowledge and experience, are all dependent on a positive attitude toward both students and learning.
Certainly, there could be little expectation of either facilitator or clinical nursing staff being responsive to student concerns, fears, or anxieties, or of them being empathie and understanding if they did not value students and learning. Because anxiety has been shown to promote further anxiety if not resolved, it seems somewhat ironic that clinical nursing staff and facilitators, as mental health professionals, do not always understand or recognize the effect their attitudes may have on students. After all, anxiety is a state with which mental health professionals are familiar and experienced in ameliorating. Indeed, without support and encouragement the anxiety students often experience in the psychiatric setting may be exacerbated.
As nursing is essentially a practice discipline many of the perceived needs, wants, and desires uncovered by this study are not surprising, and many are congruent with the findings described by other authors in other contexts. For example, regarding the desire for learning opportunities and to be involved, it is probable that the clinical practicum is seen by many students as an opportunity to learn about "real" nursing. Furthermore, it is probable that clinical education is seen as the fundamental component of the undergraduate course, and of it actually being applicable to their future employment. As the Reid Report (1994) states "the vocational goal of nursing courses is clear to students from the day they enroll in first year level" (p. xviii).
It is also not surprising that students want to feel welcome and comfortable in the setting. A sense of psychological comfort and belonging are basic human needs (Maslow, 1954). The perceived influences of the ambience of the workplace and of the clinical nursing staff support findings described by other authors (Hart & Rotem, 1994; Windsor, 1987).
This study generated information that should be useful in planning and supervising effective and mutually satisfying clinical learning experiences in any psychiatric context. Through dissemination, the generated information will hopefully provoke identification and constructive reaction from the reader. More specifically, the responses from the students who participated in this study were drawn from lived experience. They have given voice to matters that otherwise may have gone unrecognized in the curriculum. Each response represents a student's voice and, as such, should be heard. As demonstrated by the plethora of issues that have arisen from this study, the student voice must become an integral part of the alternatives from which curriculum making choice is made.
This paper has reported on a responsive evaluation study that was carried out within a university school of nursing. The aim of the study was to evaluate the clinical experience in a psychiatric setting from a student perspective and by doing so generate information that would lead to more effective and mutually satisfying nurse clinical education. The information generated has highlighted the many issues, concerns, actions, and behaviors by which the respondents judge or evaluate the quality of their clinical practicum. It is evident that the respondents were able to reflect critically on their clinical learning experience and identify strengths and weaknesses not only in the actions and behaviors of others, but also in their own. The generated information has significance for all stakeholders in nurse clinical education. It has special currency within educational circles that support the contemporary view of students as active participants in the curriculum decision-making process.
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