Clinical experience always has been an integral part of nursing education. The importance of preparing nurses capable of "doing," as well as "knowing," has meant that clinical education has remained a significant component of nursing curricula (Dunn & Burnett, 1995). Synthesis of classroom theory occurs in the clinical setting. It is in this environment that classroom theory becomes reality for students. The clinical arena stimulates students to use their critical thinking skills for problem solving.
One of the five components of critical thinking for nursing judgment is experience (Kataoka-Yahiro & Saylor, 1994). In fact, lack of practical experience can hinder the development of critical thinking (Kataoka-Yahiro & Saylor, 1994). According to Benner (1984), practical knowledge in an applied discipline is only developed through clinical experience. Ferguson (1996) indicated that:
The role of the clinical educator is to promote integration of theory and practice; provide an optimal learning environment; develop relationships characterized by a positive regard for the individual; and structure learning experiences which facilitate the acquisition of clinical skills of nursing (p. 836).
Four major problems in clinical settings that hinder optimal learning are identified in the literature and through practical experience:
* High student to faculty ratios (Schuster, Fitzgerald, McCarthy, & McDougal, 1997).
* Increasing patient acuity (Kleehammer, Hart, & Keck, 1990).
* Student anxiety (Kleehammer et al., 1990).
* Faculty concerns about patient safety (Schuster et al., 1997).
Financial constraints of higher learning institutions have dictated a 1:10, or at the least a 1:8, faculty to student ratio (Schuster et al., 1997). Individual facultystudent interaction diminishes as student numbers rise.
In acute care areas, patient acuity is increasing greatly. Patients who would have been admitted to intensive care units 10 years ago currently are admitted to general medical-surgical units, and patients who previously would have been admitted to medical-surgical units are now cared for at home, perhaps with home care assistance.
Students reported high anxiety levels in the clinical area, compared to classroom or laboratory experiences (Kleehammer et al., 1990). The literature supports that mild anxiety actually may enhance learning. However, an inverse relationship exists between anxiety and learning- as anxiety increases, learning decreases (Audet, 1995). The three major causes of student anxiety in the clinical setting, as reported by Kleehammer et al. (1990), iure related to:
* Fear of making mistakes.
* The initial clinical experience on a unit.
* Performing clinical procedures.
Anxiety was expressed by both juniorlevel and senior-level students. However, higher levels of anxiety were expressed by junior-level students (Kleehammer et al., 1990).
Underlying all student-patient interactions is the necessity to maintain patient safety. As the faculty-student ratio exceeds 1:8 and patient acuity and student anxiety increase, faculty express concerns regarding patient safety (Schuster et al., 1997). To maintain patient safety, students may be rotated off the clinical units, assignments may be modified, and experiences may be bypassed (Schuster et al., 1997). These modifications diminish the overall quality of the learning experience.
Beginning-level medical-surgical faculty at a small private college faced the challenges of creating a clinical learning environment that met student learning needs, decreased student anxiety, and maintained patient safety. The use of preceptors has become popular nationally. However, because of limited acute care sites and, thus, limited numbers of available preceptors, this method of clinical instruction was not widely available. Borrowing a method from the natural sciences, a clinical laboratory teaching assistant role was developed.
The concept of a teaching assistant in chemistry, biology, and other natural science laboratories is not new. These disciplines consistently have used a graduate student or, in the case of settings without a graduate program, an excellent seniorlevel or junior-level student with a major in science, as an assistant to the professor in lower-level science laboratory experiences. Teaching assistants help novice students set up and perform experiments, evaluate their results, and maintain student safety in the laboratory.
Using the natural science model, two excellent senior-level nursing students were selected to pilot the teaching assistant role. The selected students had completed all of their medical-surgical clinical experiences and were functioning academically and clinically at the top of their class. They were assigned to help juniorlevel faculty on a general surgical floor during the first day of a 2-day clinical experience.
After 4 weeks, junior-level students were asked to evaluate the teaching assistant concept, specifically if the assistants were helpful to them, and if they would recommend continuing the program. The responses were overwhelmingly positive. Faculty also were impressed with how well the students functioned and with the positive responses from staff nurses and patients. The program currently in use in all junior-level adult acute care and ambulatory surgery settings was developed based on this experience.
Qualifications and a job description for the teaching assistant position were developed. Students are hired through the college work-study program and are paid as they woidd be for any work-study position. The junior-level faculty identify students whom they feel would be excellent teaching assistants based on prior clinical performance, academic standing, and faculty recommendations. Students must be seniors in the nursing major who have completed all of their medical-surgical clinical experiences, which include:
* General surgical.
* Intensive care unit/critical care unit.
* Home care.
These students are encouraged to apply for the position. Students consider it an honor to be asked to be a teaching assistant and regard this job experience as an asset for their employment resumé. Because the position is available only during the spring semester, the selected students work in the skills laboratory in the fall semester to help junior-level students with skills practice. These same students also function as tutors for junior-level students who have classroom difficulties. Therefore, they can be offered a year-long work-study contract.
At the end of the fall semester, the students who will be the teaching assistants are oriented to the position. At this time, a schedule is arranged that accommodates their individual academic programs for the spring semester.
During the spring semester, juniorlevel medical-surgical students come to the clinical units the afternoon before beginning actual patient care to gather data on their assigned patients. The teaching assistants assigned to these units also come during this data gathering time to help the faculty with student questions. The teaching assistants wear name pins, which identify them to both staff and patients. Faculty introduce them to patients as senior teaching assistants. The next morning, the teaching assistants meet with the faculty 15 minutes before the junior-level students arrive. At that time, the faculty provide the teaching assistants with specific assignments for the morning clinical experience. Assignments may include helping a junior-level student:
* Assess and irrigate a nasogastric tube.
* Assess a chest tube.
* Remove a Foley catheter.
* Completing an uncomplicated sterile dressing.
* Ambulate a surgical patient.
Teaching assistants are not allowed to supervise medication administration. At appointed times during the morning, the faculty meet with the teaching assistants to reassess how the experience is proceeding and make further assignments. At the end of the morning experience, the teaching assistants can help students with flow sheet and computer documentation. The teaching assistants stay on the unit for approximately 4 hours. They do not attend the conference that follows the clinical experience.
Teaching assistants are not involved in the evaluation process of junior-level students. The clinical instructors meet outside the clinical arena with the teaching assistants and ask for objective, informal observations about students. However, the faculty are solely responsible for clinical evaluation of students.
There are many benefits of this program, including:
* A decrease in student anxiety.
* Increased faculty comfort regarding patient safety.
* More hands-on opportunities for students.
* Availability of additional role models.
* Increased collegiality among students.
A decrease in anxiety during the clinical experience was expressed on course evaluation forms. Students attributed this to the presence of another knowledgeable person (i.e., the teaching assistant) in the clinical area whom they could ask for help when faculty were unavailable. When asked on the senior exit survey, "Did the teaching assistants support your clinical performance?," 87% of students indicated a positive response.
Faculty described increased comfort related to patient safety because there was another resource available for student questions and guidance. Faculty concern about unsupervised beginning students making mistakes was decreased.
The availability of teaching assistants allowed beginning students to participate in hands-on opportunities that often would not have been possible because of the unavailability of faculty.
Senior-level students provided additional role models, especially in the areas of time management and patient communication. According to Nichols and Lachat (1994), "students may benefit from rolemodeling from a peer group of upper-level students" (p. 46). In addition, Sedlak (1997) noted that by observing other health professionals and peers, students may challenge themselves to think about their nursing practice and identify areas for improvement.
Collegiality is developed among students as they take time to support and listen to one another (Sedlak, 1997). Engaging in dialogue and sharing clinical experiences may facilitate students' critical thinking and also decrease stress in beginning students.
There was only one challenge in implementing this program. Senior-level students sometimes have difficulty scheduling the time demands of this position around their current senior-level classes and clinical experiences. Junior-level and senior-level course coordinators have worked cooperatively to alleviate this problem.
This program has been used for the past 6 years with increasing success. Faculty feel it has enabled them to provide more learning opportunities in the clinical area. It has allowed them to continue to provide quality clinical experiences, even as patient acuity and student-faculty ratios increase. It has decreased beginning students' anxiety concerning caring for patients with acute illnesses and promoted collegiality among junior-level and senior-level students. Although much research still is needed in the area of clinical education, the teaching assistant program is one innovative strategy to promote optimal learning and safe, quality patient care within the confines of rising patient acuity and institutional financial constraints.
- Audet, M. (1995). Caring in nursing education: Reducing anxiety in the clinical setting. Nursing Connections, 8(3), 21-28.
- Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA Addison- Wesley.
- Dunn, S.V., & Burnett, P. (1995). The development of a clinical learning environment scale. Journal of Advanced Nursing, 22, 1166-1173.
- Ferguson, D.S. (1996). The lived experience of clinical educators. Journal of Advanced Nursing, 23, 835-841.
- Kataoka-Yahiro, M., & Saylor, C. (1994). A critical thinking model for nursing judgment. Journal of Nursing Education, 33, 351-355.
- Kleehammer, K., Hart, A.L., Keck, J.F. (1990). Nursing students' perceptions of anxietyproducing situations in the clinical setting. Journal of Nursing Education, 29, 183-187.
- Nichols, M.R., & Lâchât, M.F. (1994) Senior-led freshman groups: A strategy for professional development. Nurse Educator, 19(6), 46-48.
- Schuster, P., Fitzgerald, D.C., McCarthy, P., & McDougal, D. (1997). Work load issues in clinical nursing education. Journal of Professional Nursing, 13, 154-159.
- Sedlak, C. (1997). Critical thinking of beginning baccalaureate nursing students during the first clinical nursing course. Journal of Nursing Education, 36, 11-17.