Interest in older person care begins during nursing education, as clinical placement in LTC provides nursing students with the opportunity to learn about the complexities of this setting. However, there is research to suggest that students may not be fully engaged in the LTC placement experience due to faculty perceptions of this setting as a missed opportunity to learn advanced nursing skills (Abbey et al., 2006; Banning, Hill, & Rawlings, 2006; Wade & Skinner, 2001). These perceptions hinder the potential to learn about the rich opportunities within gerontological nursing. Educators need to find innovative strategies to facilitate a positive and more effective learning experience in the interest of quality older person care.
Facilitating critical reflection as a learning methodology shows promise as an effective approach to student learning in clinical settings (Mann, Gordon, & MacLeod, 2009). Active methods of critical reflection that facilitate engagement with others enhance double-loop learning (Greenwood, 1998). Critical reflection processes may aid students in deconstructing clinical situations and relevant contexts, as critical reflection offers a way to discover and uncover knowledge hidden within experiences (Schön, 1983; Titchen & McCormack, 2010).
This work is theoretically underpinned by critical creativity, which is situated within the larger realm of practice development. Practice development is a movement that originated in the United Kingdom and seeks to create person-centered cultures within health care. Practice development methods, supported by critical creativity, use novel methods to promote continuous learning and transformation of individuals and cultures (Manley & McCormack, 2003). Applying these methods in an educational context can structure critical reflection in a way that taps into students' multiple senses and ways of knowing. Critical creativity blends critical reflection and creativity to access embodied knowing and deconstruct situations in search of deeper meaning (Titchen & McCormack, 2010). Key to critically creative learning methods is the role of an expert facilitator, who possesses extensive knowledge and skill in practice development methods. Crisp and Wilson (2011) offered a framework that describes the attributes and skills of a practice development facilitator on a continuum, as the training is intensive and deeply reflexive. An expert facilitator is able to simultaneously challenge and support learners, as well as guide the learner through the learning experience.
Critical reflection learning methods, when underpinned by critical creativity, give rise to activities and learning processes that combine the learners' cognitive and creative insights in an engaging manner (Titchen & McCormack, 2010). Such methods are different from traditional critical reflection strategies, as with critical creativity, the learner participates in critical reflection and creative activities led by an expert facilitator. An expert facilitator has a unique skill set that supports their work in challenging or uncertain contexts (Larsen, Maundrill, Morgan, & Mouland, 2005). The use of expert-facilitated critical reflection in an academic setting can support nursing students in deconstructing their experiences from LTC placement and reconstructing a renewed understanding that incorporates their new insights and embodied knowing.
The assumptions, anticipations, and realizations of fourth-year undergraduate nursing students regarding aging, gerontological nursing and LTC, were explored using a qualitative descriptive design, as they engaged in facilitated critical reflection activities during their LTC placement.
This study used a qualitative descriptive research design to support a description of participants' experiences of taking part in critical reflection activities during their LTC placement. This study commenced following the approval of the university research ethics board. A convenience sample of six participants met the following inclusion criteria, as each was a fourth-year undergraduate nursing student, and participating in an LTC clinical placement. Prospective participants were given flyers containing information regarding the study at their fourth-year orientation session. The researcher (A.I.) was present to answer student inquiries and emphasize that the study participation would not influence academic standing, as faculty would have access to anonymized data only. The members of the research team present at the workshops were a graduate student (A.I.), and nonfaculty expert facilitator (N.J.). The members of the research team that were faculty at the institution (S.E., K.L.) did not have access to any data containing participant information. Faculty members were given no information regarding which students opted to participate in this study.
The primary researcher completed the data collection. The expert facilitator conducting the workshops was not faculty at the institution where this study was conducted. Participants willing to participate contacted the researcher via e-mail.
The researcher and expert facilitator worked closely to develop two critical reflection workshops (CRWs), each to be administered before and after participants had taken part in their LTC clinical placement experience. The CRWs consisted of a series of activities underpinned by critical creativity, each with the purpose of helping students to critically reflect on anticipations, assumptions, and realizations related to their experiences of LTC. Each CRW was 4 hours in length and took place on the university campus.
CRW 1 took place before students had entered the LTC setting. To explore assumptions, the facilitator engaged participants in several critically creative activities. To begin, participants each selected an object that expressed their perception of LTC, for the purpose of making assumptions explicit. Next, the group took part in a guided imagery activity led by the expert facilitator to envision their personal journey of aging, which aided participants in exploring their own beliefs regarding aging. Participants each created an art installation to visually represent their aging journey. In pairs, participants shared their aging journeys with each other to capture key words used to describe their understanding of aging. As a large group, the participants shared their key words, which were grouped and discussed to establish a shared definition of aging. The participants then took a walk outside to meditate on their shared definition of aging. To conclude, participants were invited to select a few cards with various words and phrases, to summarize their anticipation and intention for their LTC placement.
CRW 2 took place approximately 2 weeks after participants completed their LTC placement. The primary purpose of CRW 2 was to engage participants in deconstructing their experiences and revealing realizations or shifts in thinking related to aspects of LTC, such as the setting, the gerontological nursing role, and aging. First, each participant shared a narrative of their LTC experience, in which the expert facilitator followed up with a few probing questions to elicit a fulsome description. Next, participants worked together to create a graffiti board to depict their collective understanding of aging. This created a space for participants to reflect on how their thoughts and beliefs related to aging may have changed during their LTC placement. Finally, participants engaged in meaningful dialogue to complete a few shared vision statements defining the ultimate purpose of gerontological nursing.
Data Collection and Analysis
Each CRW was audiorecorded and transcribed verbatim. The researcher engaged in participant observation and recorded observational and reflective field notes to capture data related to nonverbal expressions, movements, or interactions of participants and researcher reflections. Content analysis was used to analyze the transcripts and field notes, as it supported the description of a multifaceted phenomenon, such as a student learning experience (Elo & Kyngäs, 2008). During analysis, the researcher was immersed in the data and coded the transcripts and field notes; the codes were then grouped into subcategories, then into larger categories (Elo & Kyngäs, 2008). Each round of data analysis was shared with the research team and consensus was met before finalizing the main categories. To enhance rigor, the research team engaged in rounds of analysis and used critical dialogue to resolve discrepancies.
Students' assumptions, anticipations, and realizations regarding aging, gerontological nursing, and LTC were revealed in four main categories, which reflect students' learning and evolving understanding from the start to the end of their placement.
Exploring the Therapeutic Nurse–Resident Relationship
Participant perceptions of aging were initially optimistic, as supported by the co-created definition of aging with themes of “strength, growth, achievement, peace, connections, and reflecting on the journey” (CRW 1). The participants also described how aging within a LTC setting differs. The following metaphor emerged from the meditation on the shared definition of aging:
You see the trees and the flowers and the mulch and everything and it's…this man-made creation of nature and it's not in its natural environment. So, it made me think of…how we put old people into this box…and this is how they should be. We have this picture of them and it's not like truly who they are. And it's also related to how nursing homes are institutionalized and how we make it how we think it should be. And instead of looking at nature in it's wild, natural environment, when it's so much more beautiful and the flowers can just grow as they are.
This dialogue laid the foundation for participants to share their anticipations for their LTC placements regarding how they might enhance older person well-being. These intentions were shared during the final activity in CRW 1, when each participant chose a card with a key word embodying what they hoped to bring to their LTC placement. In the following quote, participant 1 described the selected cards: “The shine card. I want to be someone that can lift people's spirits. I know that long-term care can be a depressing place…by smiling or greeting people, asking them how they are can be like a light to them.”
In CRW 2, the participants described ways in which they supported residents and expressed an awareness of how gerontological nurses engage in therapeutic relationships. This was captured in the final shared statement, which highlighted that optimal care may be achieved “by a system that is passionate about gerontology, with caring and positive attitudes and beliefs, and being equipped with the right skills, approaches and resources” (CRW 2).
Navigating Preceptor Relationships
In CRW 1, participants demonstrated a limited awareness of the role that the nursing staff, particularly their preceptor, would have in their learning experience. However, participants had the opportunity in CRW 2 to express the extent to which their relationship with their preceptor shaped their experience of LTC. Participant 3 described a time when the preceptor expressed feelings of frustration:
The first few weeks I was there, she would do the medications with me. She would get kind of frustrated because it was taking too much time to do that. And she would make it very known that she was getting frustrated with me for taking too much time.
Communication was identified as the largest barrier to a building a supportive relationship, and participant 5 described how this impacted the learning process:
I think that communication is like the biggest thing. She didn't explain things very well so I kind of just had to figure things out on my own. I was like how do I this dressing? And she was like you just do this, this, this, and this. And I'd be like okay. And I'd be like I'll just figure it out.
Expanding Awareness of Context
In CRW 1, participants did not elaborate on the LTC context and instead explored their thoughts and beliefs related to aging and cultivating therapeutic relationships with residents. In contrast, many of the participant experiences in CRW 2 highlighted ethical dilemmas related to lack of time to provide appropriate care, heavy workloads, and hierarchical organizational structure.
All the participants mentioned time as a key barrier to the providing the level of therapeutic care that they had envisioned in CRW 1. Participant 3 reflected on how she felt, given the limited time to provide patient-centered care:
I was so dissatisfied. I kind of felt powerless there or isolated there a lot of the time. It was hard. If I was really busy doing all of the meds, it would be super stressful for an hour giving out the meds. And they wanted something, it was like, oh I don't have time to talk to you.
Participant 6 emphasized how the team structure impacted care:
The way that the higher people, like the DOC [director of care] and RN treated the other workers, like the PSWs and RPNs, it wasn't very nice. And communication was just not there…the structure made everything not work.
At the end of CRW 2, participants had engaged in critical dialogue that explored the role of context, as it impacts nursing practice in LTC.
Embracing Many Feelings
Participants described anticipations, assumptions, and realizations regarding aging, gerontological nursing, and LTC framed largely in regard to relationships and context, but also in relation to their feelings. In CRW 1, participant 2 used a metaphor of a ball of yarn to describe her anxiety and excitement for placement:
This was me in the beginning. A ball, really anxious…but after going to orientation…. I was able to loosen up. I got excited for opportunities, so it's like unraveling the yarn and hopefully making something beautiful out of it.
At CRW 2, the heavy emotional atmosphere reflected dialogue related to themes such as navigating the contextual challenges and relational difficulties with preceptors. However, field note data described moments of empathy when participants shared their narratives, evidenced by shared laughter, head nodding, and furrowed brows. By sharing difficult experiences, participants were able to realize similarities and support one another. After each workshop, the participants commented on their learning. At the conclusion of CRW 1, participant 4 offered the following sentiment:
This is very helpful in preparing me for placement and reflecting on my expectations. What do I want to be in this placement? I think that it's the perfect way to start…. It's given me a new perspective, which is just great.
Implications for Nursing Education
The findings from this research study have shed light on what students learn during LTC placement, as well as how students prefer to learn in this setting. The participants in this study initially described healthy views of aging and sincere intentions to facilitate healthy aging for residents. However, the participants demonstrated the difficulty of providing person-centered care due to contextual barriers. This suggests that student learning was not limited by negative attitudes toward aging, but instead by navigating the complexity of LTC. This distinction clarifies literature, suggesting that nursing students hold negative views of LTC (Celik, Kapucu, Tuna, & Akkus, 2010; Henderson, Xiao, Siegloff, Kelton, & Paterson, 2008; Moyle, 2003).
Regarding how the students learned during their LTC placement, the preceptor–student relationship was critical in helping students to make sense of the complex LTC setting. However, preceptors had little time to provide this support. Participant learning was enhanced by the CRWs, as the expert facilitator helped them to reframe experiences and offered new perspectives, suggesting educators can examine innovative ways to provide ongoing support for students throughout their LTC placement. This study adds to the literature highlighting the critical role of the preceptor and the need to support the preceptor role (Berntsen & Bjørk, 2010; Carlson & Idvall, 2014; Robinson & Cubit, 2005). In addition, the expert facilitator is a role that could be taken on by educators with expertise in the clinical specialty area and additional training in skilled facilitation principles. Educators may harness the potential of using skilled facilitation, underpinned by critical creativity, in small groups to provide frequent support to students throughout placement. Future research is needed to examine the ways in which creative methods and expert facilitation could enhance student learning and bridge theory-to-practice gaps. Further exploration could describe the use of these methods during clinical placement, as students are confronted with the complexity of the practice environment, regardless of clinical specialty.
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