Clinical education is a key component in the practice of nursing (Ard, Rogers, & Vinten, 2008; Brown, Nolan, Davies, Nolan, & Keady, 2008; Papathanasiou, Tsaras, & Sarafis, 2014; Tanda & Denham, 2009). This clinical education occurs within the context of nursing shortages, economic pressures (World Health Organization, 2013), increased patient complexity (Fedarko, 2011), quicker turnover of patients, and nursing staff shortages (Foley, Myrick & Yonge, 2012; Forbes, Hickey, & White, 2010). Yet, little research has been conducted from the perspective of individuals engaged in clinical education (Dahlke, Baumbusch, Affleck, & Kwon, 2012), leaving questions about how faculty navigate the challenging terrain of increased patient complexity and clinical environments while providing nursing education.
Researchers identify individuals who teach nursing students in clinical settings by a variety of titles. In this article, the title clinical faculty (CF) is used to refer to individuals who work in a university and teach nursing students in clinical practice settings. This could include permanent, part-time, or sessional faculty who may or may not also teach theory courses. The emerging body of literature that examines clinical education from the CF perspective suggests that the CF role is complex, due to balancing two worlds—the academic world, which requires knowledge of the curriculum and student evaluation, with an emphasis on providing quality student learning opportunities (Foley et al., 2012; Forbes et al., 2010; Heshmati-Nabavi & Vanaki, 2010; Hossein, Fatemeh, Fatemeh, Katri, & Tahereh, 2010; Wiens, Babenko-Mould, & Iwasiw, 2014), and the clinical environment, where RNs are focused almost exclusively on their patients (Henderson et al., 2010) and can be unhelpful or unkind to students (Babenko-Mould, Iwasiw, Andrusyszyn, Laschinger, & Weston, 2012; DeWolfe, Laschinger, & Perkin, 2010; O'Mara, McDonald, Gillespie, Brown, & Miles, 2014; Papathanasiou et al., 2014). To those not familiar with such clinical environments, they can seem disorganized (Andrews & Ford, 2013; Cranford, 2013; Peters, Halcomb, & McInnes, 2013), requiring CF to be adept at “juggling the dynamics of the clinical unit, staff, and specialties on the units” (Bell-Scriber & Morton, 2009, p. 85). Navigating those dynamics can be challenging due to multiple role expectations for which CF feel they may be inadequately prepared (Andrews & Ford, 2013; Cranford, 2013; Peters et al., 2013; Whalen, 2009; Wiens et al., 2014). The role of CF is made more challenging by ineffective communication and poor relationships between universities and clinical agencies (Andrews & Ford, 2013; Cranford, 2013; Peters et al., 2013; Whalen, 2009). To provide quality learning experiences, CF believe they require practical information about educational techniques and processes, as well as supportive formal structures within their universities (DeWolfe et al., 2010; Mårtensson, Engström, Mamhidir, & Kristofferzon, 2013; Raines, 2012).
Clinical placements are complex social environments, where teamwork, leadership, patient advocacy, and collaborative relationships are demonstrated in a range of staff nurses' behaviors. Nursing students pay attention to staff nurses' professional behaviors, viewing them as role models (Babenko-Mould et al., 2012). Researchers suggest that the relationships nursing students have with staff nurses and CF in clinical experiences have a profound effect on the students' professional socialization (Croxon & Maginnis, 2009; Hossein et al., 2010; O'Mara et al., 2014). Challenging relationships with staff nurses and CF can have a negative impact on nursing students, and positive relationships can act as a buffer in negative clinical situations (O'Mara et al., 2014). Positive relationships help students to gain a sense of belonging in a clinical unit, which enhances their ability to learn (Levett-Jones & Lathlean, 2008). Scholars also have found that nursing students' feeling of belonging was directly related to their self-concept and self-efficacy; conversely, a diminished sense of belonging prohibited learning because the student was instead concentrating on how to fit within the clinical environment.
CF who engage in empowering teaching behaviors can influence students' professional socialization and promote positive clinical practices (Babenko-Mould et al., 2012; Hossein et al., 2010; O'Mara et al., 2014). Yet, little is known about how CF navigate relationships within clinical settings to foster a sense of belonging that enhances nursing students' learning. Given that clinical environments are becoming increasingly complex, understanding how to better support CF in creating quality learning experiences is vital. Thus, the aim of this study is to understand CF's perspectives of what supports and what hinders their ability to foster student learning.
As a first step in understanding how to support CF in the university's Bachelor of Science in Nursing (BSN) program, the authors conducted a survey (not reported in this article) and asked CF to participate in a focus group. The survey was placed in the mailboxes of all nursing faculty who work in a small university in western Canada, with an invitation provided at the end of the survey to participate in a focus group. This article reports the thematic analysis of data derived from the focus group. Ethical approval was obtained from the university prior to conducting the study. The authors' research assistant received all of the completed surveys, determined who had indicated an interest in participating in the focus group, and e-mailed information about participation and a consent form to each individual. Five CF (of a faculty staff of 30) volunteered to participate in the focus group. Participating CF had completed a master's degree and had 1 to 15 years of teaching experience.
At the beginning of the focus group, participants were given the opportunity to ask questions, and confidentiality was discussed (participants agreed to keep issues discussed in the focus group confidential). The focus group was guided by semi-structured questions, including “How do you facilitate clinical education?” “How are you supported in your clinical work with students?” “What are the challenges to clinical education?” “How do you address the challenges to clinical education?” and “What do you think is important for us to know about clinical education?” Responses were audio recorded and transcribed verbatim.
Thematic analysis was used in the current study. The researchers engaged in data analysis independently. They then met and discussed the similarities and differences in thematic analysis and their perceptions of the important themes. In this way, comparative analysis supported inductively derived themes (Loiselle & Profetto-McGrath, 2011). The trustworthiness of the current study was established by paying attention to credibility, dependability, confirmability, and transferability (Lincoln & Guba, 1985). Credibility was enhanced by triangulation of the data analysis between the researchers. The dependability of this study was supported through the range of level of experience among the participants. Confirmability was promoted through the iterative process used by the researchers. The transferability of this study is enhanced by the thick description provided in the findings and in explanations of the research process.
Analysis of the data revealed stressors within the clinical environment and insufficient formal support from the university, which created challenges to effective clinical teaching. Supports to clinical teaching were identified as the relationships CF developed with other faculty and the clinical staff. CF identified “a big gap [in] communication” (CF 1) between clinical settings and the university. They also reported challenges in “facilitating learning in high-stress units with high turnover and very high acuity” (CF 2). As one CF explained, “A lot of nurses in this area are exhausted and don't want any more students. I've talked to some nurses about that and [they said] it is because the students are challenging” (CF 3).
RNs in the units who were struggling to adapt to changing nursing care delivery processes and increasingly acute patients found that the presence of students was yet another stressor. As a result, RNs were less available and less receptive to students' questions or they might “pick on students” (CF 2); thus, students were relying almost exclusively on CF and were minimizing their interactions with the RNs. This meant that CF “need to spread [themselves] so thin in such a really volatile and hostile environment” (CF 1) to support student learning. To cope with these challenges, some CF asked other CF for support in how to best balance student priorities and develop relationships that could enhance their ability to become more than a “guest,” which would ultimately provide better student learning experiences. The term guest used in this article denotes CF as not belonging to the clinical setting.
Balancing Student Priorities
CF took many details into consideration to determine which students took precedence for their attention at any given time. To support these decisions, CF relied on their nursing knowledge and experience, their knowledge of the students' skill level, and their knowledge of the nursing staff. One participant explained:
I prioritize it depending on the acuity of the patient, who the student is, the nurse, and the type of patient. It [the priority] shifts with the environment because you [may] have a strong student and a certain patient and a nurse with levels of openness and [who] includes students, or they just leave the patient to the students. I can't be in eight places at once with eight students, so it's a balance of all factors. It's priorities. (CF 4)
Such balancing requires that CF be familiar and comfortable with the types of patients in the unit, as well as the students and the nurses. CF needed to be able to trust that RNs would address concerns and advise them about student issues, to coach students in encouraging ways, and to have the best interest of the students in mind. Unfortunately, not all of the nursing staff displayed positive attitudes. One participant reported:
[The CF had to] deal with negative Nellies who have questionable professional ways of being and think students should be able to do more than they do and push the envelope for students to do things outside of their scope. (CF 3)
In those types of situations, students may feel pressured by RNs to engage in activities beyond their scope of practice. Some CF turned to experienced faculty for guidance in navigating these challenges, as demonstrated by one participant's comment: “If I had a problem, I could walk up a flight of stairs and [experienced faculty] would be more than happy to either hear through my issue or offer suggestions” (CF 3). Practical suggestions were valued by the CF.
CF believed that fostering trusting relationships with students also helped them in balancing priorities according to the skill level of the student and preventing students from engaging in activities beyond their scope of practice. Fostering trust required the use of “good people skills, so students feel safe to ask questions and they can tell you when they are feeling uncomfortable” (CF 5). To foster trust, it was necessary to be approachable and to interact with students in ways that promoted a safe environment for learning.
Establishing formal and informal relationships with other faculty members and clinical staff helped CF to find learning opportunities, get support in balancing priorities, and establish constructive learning environments. The support provided to CF by experienced faculty included coaching and mentoring, problem solving, sharing of teaching strategies, and explanations of the curriculum. CF purposefully nurtured connections with clinical staff and other faculty to enhance their clinical teaching. However, nurturing connections with clinical nurses who were experiencing workload stressors was not easy, as suggested by one participant: “It's a bit of a tight rope because we are guests on a unit. And, yes, nurses have a professional responsibility to mentor students, but we are guests” (CF 4).
The perception of being a guest was somewhat easier if the CF had “been a direct care nurse” (CF 3) previously in that unit. CF made a conscious effort to demonstrate their nursing knowledge and to develop personal relationships with members of the nursing teams so they could move from being seen as an outsider to someone who could be considered as part of the team. They developed “personal relationships with practice teams by having coffee with BSN colleagues and clinical staff” (CF 5). These relationships were important because if the clinical staff trusted the CF, they would be more likely to support student learning and raise concerns about students, which would ultimately assist CF in balancing their student priorities.
The process of building a trusting relationship with the CF took time, while the unit staff observed how the CF interacted with students and staff. CF assigned to a new clinical setting reported that “it's very hard for you to get the relationships you need that are crucial for success in practice” (CF 3). Mentorship from more senior faculty was supportive in establishing the necessary relationships. As one participant stated, “My experience as a newcomer is that clinical faculty are very open to sharing whatever they have and sharing of themselves” (CF 2). These informal mentors introduced new CF to clinical staff who could be helpful in providing learning opportunities for students and provided tips on how to establish relationships with clinical staff. CF adopted a common strategy of introducing themselves, having their students introduce themselves, and explaining their scope of practice to the clinical staff. This was understood to “help students learn and staff to learn” (CF 4) about one another. This strategy also taught students how to develop relationships and allowed staff to learn the scope of safe practice for the students.
Time spent in one practice area over several semesters was also seen as an opportunity to develop relationships, as noted by one participant:
I've been at the same unit a few semesters in a row and they recognize me and that's very helpful. It contributes to student learning. Consistency with an area is useful. (CF 1)
When clinical staff had a relationship with the CF, they were more likely to highlight potential opportunities for student learning and engage with students in the learning process. When CF were new to a clinical site, they struggled with “a nebulous sense of belonging [and having] a team of faculty was really vital to feel supported” (CF 4). Having other CF to mentor, to share teaching strategies with, and to understand the feeling of being a guest was a vital support that enabled them to facilitate student learning.
A key finding from the current exploratory study is the importance that CF gave to developing relationships with students, clinical staff, and other faculty as a means of leveraging student learning. Relationships were identified by CF as being vital supports to their clinical teaching. Although the importance of relationships in nursing education have been highlighted by many researchers (Ard et al., 2008; Forbes et al., 2010; Heshmati-Nabavi & Vanaki, 2010; Hossein et al., 2010; O'Mara et al., 2014; Wiens et al., 2014), the current study provides insight into how CF use their personal social capital to provide a sense of belonging for their students and themselves. Social capital is understood “as the good will that is engendered by the fabric of social relations and that can be mobilized to facilitate action” (Adler & Kwon, 2002, p. 17).
Other researchers have explored how nursing students' sense of belonging influences their ability to learn in clinical placements (Levett-Jones & Lathlean, 2008). If students did not feel they belonged, they expended considerable energy in becoming part of the team. Similarly, in the current study, CF expended considerable energy developing relationships to change their position of outsider, or guest, to one colleague and part of the staff in the clinical unit. They wanted to belong, and they wanted their students to belong. Belonging was seen as key to leveraging better student learning. Other, more experienced CF supported them and guided them in identifying strategies to develop relationships with the clinical staff. Although other researchers have identified the positive impact of a supportive network on CF's success (Andrews & Ford, 2013; Ard et al., 2008; Bell-Scriber & Morton, 2009; Cangelosi, Crocker, & Sorrell, 2009; Shahsavari, Parsa Yekta, Houser, & Ghiyasvandian, 2013), the current study demonstrates how CF can use their social capital to create supportive relationships. CF supported one another by sharing teaching strategies and tips on how to better use their social capital to develop relationships with clinical staff.
In the current study, the CF alluded to the possibility that formal support from the university needed improvement, particularly around communication with the clinical settings. At the time of the study, no formal orientation or mentorship program was in place for CF. Other researchers have identified that CF would like more formal education and support for their teaching role (Andrews & Ford, 2013; Gazza & Shellenbarger, 2005). As a result of the current study, the authors have established a quick-reference communication guide that identifies individuals at the university who CF can call regarding questions about policy or practice concerns, and they established a formal university orientation and mentorship program for CF. The authors believe this is an area that requires more research to determine the relationship between formal support provided by a university and how CF can leverage that support into social capital to expedite their sense of belonging in clinical settings.
Although this exploratory study represents only one educational setting, the findings may have relevancy for other educational institutions. Also, the current study did not extensively examine the relationship between the university and CF; this is also an area for future research. Understanding the ways that CF can be supported to use their social capital to foster their own and their students' sense of belonging in clinical settings will ultimately improve students' learning experiences.
The current exploratory study revealed that CF are teaching BSN students in challenging clinical settings that are associated with high patient acuity, complexity, and change. To navigate these challenges, CF are balancing student priorities based on patient acuity, their knowledge of the nurses in the unit, and the skill set of the students. Key to their ability to facilitate learning opportunities is the support the CF receives from other CF to guide them in developing relationships with clinical staff and students. Developing relationships with the clinical staff supported CF in changing their perceptions of themselves and their students from being a guest to one of being colleague and future colleague. More research is needed to understand how better to facilitate these important relationships.
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