The mainstay of nursing curriculum focuses on the development of knowledge, skills, and attitudes for professional nursing practice. Although knowledge and skills are essential for safe practice and success on the NCLEX-RN®, an outcome such as role formation is also integral to student learning. Designing innovative pedagogies to develop students' role is important for successful transition into practice but is a challenge for nurse educators. This article discusses an innovative global clinical immersion program with an intraprofessional component designed to facilitate role formation across multiple nursing degrees.
An important aspect of nursing education that is not always emphasized is the formation of the nursing role and identity. In most cases, role formation is not consciously taught but instead is considered part of the informal curriculum. As students participate in clinical experiences, they are exposed to situations and professionals that contribute to their formation in their role as nursing professionals (Felstead, 2013). Additionally, professional identity formation has been related to the concept of professional socialization, which includes interactions with individuals within the nursing profession, as well as related professions (Zarshenas et al., 2014). According to Benner, Sutphen, Leonard, and Day (2009), role formation transcends simply learning or socialization but rather focuses on the meaning and intent of nursing. This includes “transforming their ways of perceiving and acting in situations” (Benner et al., 2009, p. 86). As educators, facilitating strong and purposeful opportunities to foster this transformation can be imperative in the role-formation process and aligns with transformation called for by Benner et al. (2009).
Nursing education has been challenged to offer opportunities for students to work collaboratively with other health care professionals to promote a successful transition into practice. Although there are examples of interprofessional educational activities, there are minimal models showing effective ways to meet the curricular outcomes through collaborative activities within their own profession. Intraprofessional education is “education that occurs when two or more disciplines within the same profession are engaged in learning together and subsequently collaborating in the workplace” (Bainbridge & Nasmith, 2011, p. 4). George, Murphy, DeCristofaro, and Hucks (2018) found that students understood the importance of intraprofessional collaboration when they participated in collaborative service-learning activities that included baccalaureate nursing degree and Master of Science in Nursing students. The literature reveals limited examples of intraprofessional learning experiences that occur in the setting of high-fidelity simulation (Boothby, Gropelli, & Succheralli, 2018; Leonard, Shuhaibar, & Chen, 2010) and clinical care (Hoffart, Kuster-Orban, Spooner, & Neudorf, 2013). On the other hand, role formation has been identified as an outcome in studies that included international clinical exchange programs (Ter Maten & Garcia-Maas, 2009) and in local immersions (Hood, Cant, Leech, Baulch, & Gilbee, 2014) that did not include an intraprofessional aspect. Noticeably, the role of an intraprofessional global clinical immersion experience in facilitating role formation has not yet been explored.
At the authors' university, the global clinical immersion program was designed to provide health care to underserved communities while educating nursing students using an international clinical immersion. Specific goals were established for this global clinical placement. The first goal was to provide high-quality, safe, and ethical health care to the impoverished communities of Kingston, Jamaica. Makeshift clinics were established in different communities for 5 days during the 1-week long immersion experience in Jamaica to provide free primary care to all age groups. The same communities were visited annually in order to establish a sustainable program.
The second goal of the global clinical immersion program was to educate the nursing students using an intraprofessional model to foster their clinical competencies and role formation in nursing. The health care team included physicians, nurses, nurse practitioners, and physician assistants from faculty and the community whose goal was to educate nursing students while caring for the vulnerable population through a collaborative approach. The nursing students represented all nursing degrees offered at the University: baccalaureate, master's, and doctoral. In a typical immersion, 12 baccalaureate, six master's, and two doctoral students would travel to Jamaica for this experience. Although each student had his or her separate role on the team, the intraprofessional collaboration among the students assisted in forming their role identity for their new and emerging position in nursing.
Two orientations for the global clinical immersion program were held that included all student participants and nursing faculty. The sessions focused on introductions, cultural information, logistics, the roles of the students, and a simulated patient scenario. The simulated patient experience walked the student participants through a typical patient encounter. Using realistic patient scenarios, the students began a chart similar to what would occur in triage. After discussing a diagnosis, treatment plans were discussed from the perspective of the various nursing roles. At the end of the simulation, the students were required to prepare medications and provide health teaching. The orientation provided a foundation of expectations for the students and an initial appreciation for the various intraprofessional roles.
During the 1-week clinical immersion, day 1 consisted of preparation for the rest of the week, including team introductions and acclimation to the culture, and days 2 to 6 were community clinics. The clinics were approached similarly each day, setting up each station and rotating students through the various positions appropriate to their role, while maximizing interactions for participants with each other and patients. Unique to this experience was that in addition to the students' main role as clinicians, students from each program acted as instruments by which other students developed their role. The students were paired with colleagues in other programs. The baccalaureate nursing students' functions included triaging, conducting comprehensive assessments with a nurse practitioner student and provider or administering medications, and teaching healthy behaviors. The master's students in the nurse educator and clinical nurse leader program roles required them to oversee the baccalaureate students in these roles. As the National League for Nursing (n.d.) nurse educator's core competencies include the ability to facilitate learning, learner development, and socialization, the baccalaureate students served as the instruments for the nurse educator students to learn their advanced role in leading and mentoring. Similarly, the clinical nurse leader program students have a core competency of interprofessional communication and team leadership, requiring the students to apply their education to leading the team (American Association of Colleges of Nursing, 2013). By pairing the baccalaureate students with the master's students, the learning was mutually beneficial.
The nurse practitioner students were paired with the providers and a baccalaureate student to evaluate and treat patients in primary care, pediatrics, and women's health. The nurse practitioners mentored the baccalaureate students in their clinical abilities and learning the scope of practice as an RN. The baccalaureate students supported the nurse practitioners' appreciation for their role transition from RN to provider. The Doctor of Nursing Practice students were orientated to either the nondirect patient care roles or direct patient care roles overseeing a nurse practitioner student, depending on their previous experience. The doctoral students who are not nurse practitioners or students in that program rotated between triage and health promotion or pharmacy clinic areas to supervise the baccalaureate students and flow of the clinic. Through this, the doctoral students had the opportunity to develop their organizational leadership in working with the team as a whole. The master's and doctoral students also collaborated to complete a continuing education workshop for the Jamaican nurses at a local hospital. By pairing the students from different programs, the learning was mutually beneficial.
The intraprofessional collaboration continued during the daily debriefing sessions. The graduate students facilitated the reflective debriefing sessions, guiding discussions on patient care, comparison of health care systems, and scopes of practice for the different students. The discussions further fostered students' role formation through identification of differences among the levels of nursing and role modeling of leadership and professionalism at the meetings.
The clinical experience concluded 2 weeks postimmersion with the submission of reflective journals. The reflective journal assignment directed students to write their thoughts and insights on the learning and experience daily while abroad. The reflective journals were thoughtful in considering all aspects of their learning, including the clinical and role formation for their specific level.
The identification of learning outcomes and the evaluation process is an important part of the role-formation process. The outcomes for the experience were identified based on the course that the clinical experience was linked to in order to receive credit. Therefore, the clinical outcomes for the experience were the same as for the students who were completing their clinical placements for the same course in the United States. Each level of students has specific learning objectives they are expected to meet and both the experience and the intraprofessional team members facilitated meeting these goals.
The evaluation process is an integral part of not only ensuring that students are meeting the goals, but also part of the role formation for the master's and doctoral students. An important part of the role-formation process for nurse educator and clinical nurse leader students is accepting constructive feedback. Seemingly more important is for the students to learn how to provide feedback appropriately. The use of the evaluation process in the role formation of the students was organized to be mutually beneficial to all groups. Students received both formative and summative feedback based on the identified outcomes through multiple channels. This method of 360-degree feedback is instrumental in role formation for student nurses (Felstead, 2013).
For the baccalaureate students, formative evaluations were completed by the nurse educator and clinical nurse leader students daily. Informal conversations between the baccalaureate and the master's students provided specific examples of the learning that occurred throughout the day. These conversations were observed by the faculty in order to ensure appropriateness of the feedback, as well as to provide an evaluation of the nurse educator students' ability to provide proper and respectful feedback. Both the baccalaureate and the master's students gained important awareness through this daily exchange. In the clinical areas, the nurse practitioner students delivered feedback on the clinical knowledge and skill formation of the baccalaureate students they worked with through similar informal conversations following the clinical day. The doctoral students, depending on their previous experience, assisted faculty to evaluate the nurse educator students or the nurse practitioner students on a daily basis. Feedback was provided at the end of the clinical day and included strategies for further role formation as the immersion experience progressed.
Daily debriefing was an additional method of formative evaluation. Master's students were tasked to facilitate the daily debriefing, which included all levels of nursing students along with a faculty member. Questions were posed that encouraged reflection on their observations, experiences, and on the team process. Students were encouraged to give honest reflection on the positive and negative aspects of the team experience for each day. Faculty were able to assess the role-formation process through observations of the intraprofessional interactions.
Summative assessments were completed at the end of the experience for students in each level. The summative assessment was determined through direct observation by faculty, feedback from the intraprofessional team members, and review of the reflective journals. Reflective journals allowed students to reflect on each daily experience and how it contributed to their professional formation. Furthermore, journaling provided faculty with an insight into their transition and growth over the week-long experience. To maintain the 360-degree evaluation model, baccalaureate students were given the opportunity to provide feedback on the master's students for use in the evaluations.
Results and Program Evaluation
Effectiveness of the program was determined through achievement of the established global objectives, which included aspects of effective collaboration and role within the team process. Individual evaluations using these outcomes were completed by faculty at the end of the experience and collated. Students at all levels consistently have met these objectives. From a student perspective, opportunity to evaluate the program was obtained through anonymous automated surveys, as well as through postexperience discussion during debriefing. Overall, students reported that the experience was productive and contributed significantly to learning about their new professional role. Students commented that the use of the intraprofessional team model was instrumental in their role formation and that other members of the team contributed significantly to their learning. Students identified that in addition to the clinical expertise they obtained, they developed a strong understanding of the roles of other health care providers in the team. Students shared that the opportunity to interact with the intraprofessional team helped them to develop strong communication techniques. Overall, the theme of teamwork in the context of the value of functioning as part of an intraprofessional team was identified.
Affording students the opportunity to immerse themselves into an intraprofessional clinical experience can have an important effect on their role formation regardless of their level of nursing. Utilizing global clinical immersion experiences have benefits for the students, the university, and the community receiving the care. The intraprofessional model uses the skills of the students as a learning vehicle for other students. This method of learning is beneficial to the university because no additional resources are required than those already in place for the immersion experience. With the use of the intraprofessional model, the process of role formation is an additive learning outcome above and beyond the clinical and cultural learning that takes place. The comfort gained from these interactions and the ability to work as part of an intraprofessional team promotes camaraderie as students are working toward the common goal of caring for the vulnerable communities. Through an appreciation of the roles of the other nurses, civility within the profession can be better fostered both during the immersion and on transitioning into their own new clinical roles.
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