- Email: [email protected]
Facilitating undergraduate nurses clinical practicum: The lived experience of clinical facilitators
Nurse Education Today (2006) 26, 416–422
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Facilitating undergraduate nurses clinical practicum: The lived experience of clinical facilitators Cathy Dickson
a,*
, Jane Walker
b,1
, Sharon Bourgeois
a,2
a
School of Nursing, Family and Community Health, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 1797, Australia b School of Clinical Sciences, Charles Sturt University, Locked Bag 588, Wagga Wagga, NSW 2678, Australia Accepted 25 November 2005
KEYWORDS
Summary Clinical practicum experience for undergraduate nurses remains undisputed as an essential component of any program. Exposure to the reality of professional practice and its integration of explicit, with tacit knowledge, is invaluable in producing skilled clinicians. Currently there are many issues that have arisen regarding clinical practice education for undergraduate nurses in Australia including; ongoing financial support and resourcing of clinical placements. Developing an understanding of these issues is central to the provision of quality clinical education. The aim of this study is to reveal dimensions of the lived experience of being a clinical facilitator, a popular model of nursing clinical education, to come to an understanding of how facilitation actually takes place in the clinical environment. The Hermeneutic phenomenological approach used in this study has brought to light five essential themes that elucidate the phenomena of facilitation. Those themes have been identified as; knowing your own limitations, employing the notion of stepping in or stepping back, developing alliances, acknowledging the reciprocity of the learning experience, and identifying appropriate clinical buddies. The recommendations from this study will have an impact on current issues and will inturn, influence the quality of clinical education for all stakeholders. c 2005 Elsevier Ltd. All rights reserved.
Undergraduate education; Lived experience; Clinical facilitation
Introduction * Corresponding author. Tel.: +61 02 45701904. E-mail addresses: [email protected] (C. Dickson), [email protected] (J. Walker), [email protected] (S. Bourgeois). 1 Tel.: +61 69332577. 2 Tel.: +61 02 45701904.
Clinical practice experience at the undergraduate level is essential for the development of competent Registered Nurses. Exposure to the reality of professional practice and its integration of explicit
0260-6917/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2005.11.012
Facilitating undergraduate nurses clinical practicum with tacit knowledge is invaluable in producing skilled clinicians. As the demand for clinical readiness of our under graduates increases, the provision of quality undergraduate clinical education has emerged as a national concern. In Australia these issues have been highlighted by the National Review of Nursing Education Australia (2002) and are currently the impetus for the formation of a national task force and other initiatives. The issues relate to types of models of clinical practice experience, resourcing clinical placements and the funding for these placements (National Review of Nurse Education, 2002). To date there are multiple models of clinical education utilised by the many tertiary institutions that offer undergraduate nursing education. There appears to be little consistency, and difficulty in evaluating the effectiveness and quality of clinical education models. A number of authors claim that the goals of effective clinical education are; skill acquisition, integration of theory with practice, application of problem solving skills, development of interpersonal skills, socialisation to the informal and formal norms of the profession, acclimatisation to the protocol and expectation of professional practice and exposure to the socio-political health care arena (Conway and McMillan, 2000; Hardy, 1990; Hutchings and Sanders, 2001; Jackson and Mannix, 2001; Mahat, 1998; Mundt, 1990; Severinsson, 1998 cited in Clare, 2002). Furthermore, clinical experience enables students to become proficient in the knowledge, skills, and attributes implicit in the Australian Nursing Council Incorporated (ANCI) competencies (Napthine, 1996; Nash, 1998 cited in Clare, 2002). A dynamic clinical environment, the changing face of health care and current trends in staffing, challenge the way in which these goals are attained for undergraduate students. The tertiary institution from which participants for this study were recruited uses several models. The predominant model is one clinically current Registered Nurse, employed on a sessional basis as a clinical facilitator appointed to a group of students allocated to a designated health facility. Usually facilitators are allocated on a ratio of 1:8 students. The students are commonly distributed throughout the health care facility, which requires the facilitator to relocate for supervision or assessment of individual student learning. Individual students are then ‘‘buddied’’ with a member of staff from the facility and they perform holistic patient care with their partner for that shift. The clinical facilitator supervises students learning experiences from a supernumery position (Finn et al., 2000) during that time.
417 The aim of this paper is to highlight how facilitation takes place under these circumstances in the current clinical environment.
Literature review The literature is replete with papers that have addressed the many relevant issues and controversies that have arisen as the demand for clinical ‘readiness’ of our under graduate nurses increases. Discussion has centred on various aspects of clinical education. For example differing models of clinical teaching are highlighted in works by Clifford (1996), Cahill (1997), Langridge and Hauck (1998), and Rowan and Barber (2000). Differing methods of educating students in the clinical setting and the campaign for excellence in undergraduate clinical education are examined in the works of Bowles (1995), Davies et al. (1999), Andrews and Chilton (2000), Lo and Brown (2000), and Kelly et al. (2002). Further to this discussion, a number of authors have centred on the differing perspectives and or requirements of the students (Kotzabassaki et al., 1997; Gignac-Caille and Oermann, 2001; Lee et al., 2002), the educators (Finn et al., 2000; Phillips and Duke, 2001) and other stakeholders (Wellard et al., 1995; Cornes, 1998; Ellis and Hogard, 2003) in the provision of clinical education. However, there is little documentation on how facilitation is achieved in the complex and changing environment of the clinical setting. A working definition of facilitation is offered by Harvey et al. (2002) as, a technique by which one person makes things easier for others. Harvey et al. (2002) go on to explicate the specific purpose of facilitation in practice based learning for health care as the co-creation of new knowledge through critical reflection and dialogue between learner and facilitator. Burrows (1997) offers a deeper examination in that ‘‘Facilitation is a goal oriented dynamic process in which participants work together in an atmosphere of mutual respect, in order to learn through critical reflection.’’ (p. 401)
Method The research philosophy The phenomenological philosophy is of particular importance to nursing research as it allows nurses
418 to examine questions related to phenomena experienced in health and illness (O’Brien, 2003). Given these underlying premises, Heideggerian phenomenology will form the basis of the underpinning philosophy for this study. At the turn of last century, phenomenology was founded as a philosophy by Husserl and extended by Heidegger to include existential concepts in order to understand human consciousness and experience (Kvale, 1996). When using this philosophy in the interview situation the interviewer seeks to find meanings in the life world of the interviewee (Kvale, 1996). Heideggerian investigation of meaning attempts to step beyond the obvious and identify the underlying essence of the experience through interpreting the practical understanding of human actions and experience (O’Brien, 2003).
Sample and setting Using a purposive technique a sample of 10 participants was chosen from the population of 164 clinical facilitators from a University in Sydney, NSW enrolling undergraduate student nurses. The sample selected was subject to inclusion criteria consisting of those facilitators who have been employed in the position for more than two consecutive semesters. Of the 10 eligible participants six responses were returned. Actual sample size was determined by data saturation or redundancy, which was defined as ‘‘The point when data collection is terminated because no new description and interpretations of the lived experience are forth coming from the study participants’’ (Russell, 1999, p. 168). Data saturation was reached after 5 in-depth semi-structured interviews were completed. Four females and one male participant were interviewed. The mean age of participants was 44 (32–51), and the average length of employment as a facilitator was 12 semesters (5–20).
Data collection This study was conducted using in depth semistructured interviews based on the technique of funnelling. This type of data collection requires a relationship between the interviewer and the participant. Without an established rapport based on trust it will be difficult to elicit the in depth kind of personal beliefs and views necessary to collect appropriate data (Minichiello et al., 1995). Rapport was established with the participants by engaging in general conversation before the interview. This is important as it allows the participant to feel comfortable and able to provide more detailed
C. Dickson et al. data (Fontana and Frey in Denzin and Lincoln, 1998). Funnelling allows general non-threatening questions to be asked and then, as the rapport develops, more in depth questions can be posed (Minichiello et al., 1995). Initial questions to be posed in these interviews are designed to help the participant to begin thinking about the phenomenon in general terms, and then focus on interpreting their own feelings about issues raised. Questioning began with ‘‘Can you please tell me what brought you to become a clinical facilitator?’’ and progressed to ‘‘Can you please tell me how you facilitate learning in the clinical environment?’’ This study was conducted for the course requirement in a Master of Clinical Nursing program. Ethics approval was obtained from the University the author was enrolled in, and approval sought for access to the clinical facilitators from their employer. All potential participants were contacted by post and sent a participant information letter explaining the study, and a consent form. After obtaining informed consent, interviews were scheduled at a convenient day and time for each participant. The interviews were audio taped and transcribed verbatim by the researcher. The duration of the five interviews ranged from 45 to 60 min.
Results Data analysis After reading and re-reading the entire transcripts to gain a sense of the whole, Giorgis’ thematic data analysis (Russell, 1999) was used to find meaning in the verbatim transcripts formed from the interviews (Minichiello et al., 1995). This method was chosen because of its suitability for use with a small number of participants who have lived the experience under study. From this thematic analysis five themes emerged from the data. These are: knowing your own limitations, employing the notion of stepping in or stepping back, developing alliances, acknowledging the reciprocity of the learning experience, and identifying appropriate clinical buddies. Theme 1. Knowing your own limitations For the participants in this study, this theme seemed to be a very important starting point for clinical education of students. That is facilitation of another’s learning begins with an understanding of the self. This becomes increasingly important
Facilitating undergraduate nurses clinical practicum when the clinical facilitator is expected to assist student learning outside his or her own speciality. ‘‘I know there are people within the hospital that can help them achieve a particular focus, they may have an area of expertise that I don’t because I’m not a walking encyclopaedia by any means.’’ Participant 2 Theme 2. Employing the notion of stepping in or stepping back All participants at one stage or another used this observational strategy during the course of the practicum. The facilitators felt that they could step back from direct student interaction and hand over control of care to the student. This notion was also employed when the student was interacting with their ‘‘buddy’’. The facilitator was in effect giving over the teachable moment to the buddy. ‘‘But I’ve learned to step back a little. So that’s been a little bit hard, like when we are sponging and showering I want to take over and say ‘‘Oh this is the way you do it’’. So I’ve had to say, ‘‘you do that’’. I make sure that they are safe and then I’ll just stand there’’. Participant 4 Stepping in was employed by the facilitator when there was a judgement made by them that the student’s action would in some way be detrimental to the patient. ‘‘. . .for example a couple of weeks ago I had to help the student put a catheter in. They had seen one done before. . . and in the process of doing it, it was a difficult situation and in the end I ended up helping to the point where I did most of it and um. . . they learnt in the sense of me doing it. . . with a commentary for example’’. Participant 3 Theme 3. Developing alliances As the facilitators may not be allocated to a clinical area or facility that they are normally employed in and, have students placed over a number of clinical areas in the same facility, a large part of their time is spent on forming alliances. These alliances allow the facilitators access to areas and resources that may usually be only available to staff, allow for smooth assimilation of the students and help address any difficulties the student or facilitator might come across. The resultant effect being extending the learning experience, or exposing the student to areas of interest. ‘‘I do see it as a public relations role, being nice to the staff, smoothing the way for the students’’. Participant 4
419 ‘‘My role is very diverse, its personalities, it’s the students, the staff the administration of the hospital. I mean I have to be very flexible. I’ve got to be very understanding and diplomatic. . . .That’s an enormous amount of work but I believe that continuity of care is very important to the students. . . .Building a rapport with them and the doctors and that is something I would have to do for each area’’. Participant 5
Theme 4. Acknowledging the reciprocity of the learning experience All of the participants viewed the experience of facilitation as more of a sharing than a straightforward didactic transmission of information. It was interesting to note that some of the facilitators included the patient in the sharing of learning. Whether this occurred as a direct or indirect effect of teaching the patient actually learnt something from the communication between the student and the facilitator. The facilitators encouraged the students to involve the patient in their care. Clearly, when the facilitator acknowledges the knowledge base of the student and the patient, learning in the clinical environment can be viewed as being triangular in nature. ‘‘As a facilitator it’s not like this person, the expert, just imparting knowledge. I very much believe that it is more of a mutual learning experience. . . at the bedside. . . I can’t say how often when were in there having a little teaching session. . . and the patients say ‘Oh that’s so interesting. . .’ Its me, the student nurse, and the patient at the bedside’’. Participant 1
Theme 5. Identifying appropriate clinical buddies Participants in this study discussed the importance of linking the student with a Registered Nurse who they felt would be supportive and encouraging. They were able to identify personal and professional characteristics that help them to decide if the student would benefit from the relationship. ‘‘. . .I guess when I first go to the ward I’m looking for attitudes. . . you know. . . ‘Oh no not students again!’ so that is someone who I definitely don’t want to buddy them with. . . so I’m trying to buddy them with someone who has a more positive attitude and more dynamic in um. . . being a professional’’. Participant 5
420
Discussion The aim of this study was to uncover how facilitators actually facilitated learning in the clinical environment. The themes that were uncovered revealed the many facets of this role. The level of responsibility that the participants felt in relation to providing a quality experience for the students was overwhelming. Due to this, the level of commitment that these participants demonstrated should not be underestimated. Knowing your own limitations an examination of the self, an antecedent to facilitating clinical learning for the student, was extremely important to all the participants. Landmark et al.’s (2003) study supports this finding as their study also highlighted the fact that the quality of the experience was related to the professional self-confidence and self-awareness of the supervisor/facilitator. As a proponent of critical reflection Brookfield (1986), espouses that the development of the power of critical reflection is central to effective facilitation of learning. By acknowledging their own limitations and finding for more appropriate resources, the facilitator promotes a collaborative clinical learning environment. The notion of stepping in or stepping back as a teaching strategy relates to the facilitators skill in determining and managing aspects of learning in the clinical environment. When the facilitator deems that the student has a poor grasp of the clinical situation and that they need to step in, they are using their ‘‘skilled know how’’ (Benner and Benner, 1999, p. 25) in acting as a patient advocate. In relation to this Finn et al. (2000) discuss the unique situation clinical educators find themselves in whereby they have a three-pronged responsibility to the student, the client and the facility. By stepping back, the facilitator gives control of the experience to the student and hence assists the student develop a sense of self and, their own practice (Benner and Benner, 1999). A similar strategy was uncovered in Ohrling and Hallberg (2000) study but was referred to as nearness and distancing. This action results in decreasing the learner’s dependence on the facilitator, which is a hallmark of effective facilitation (Brookfield, 1986). Developing alliances in the clinical area has been uncovered as a theme in previous studies (Clifford, 1996; Ohrling and Hallberg, 2000; Ellis and Hogard, 2003). The participants in this study discussed spending a lot of time and effort in establishing relationships with relevant clinical staff that would prove to be conducive to the learning environment. Alexander’s study (cited in Lee, 1996) supports this finding by reporting that 50% of nurse teachers time
C. Dickson et al. was devoted to liaison. This effort not only enabled the creation of positive learning experiences, the essence of facilitation, but also widened their exposure to complementary areas of nursing practice. Dunn and Burnett (1995) list factors that commonly influence the learning environment that include interpersonal relationships, and atmosphere and attitudes. Clearly, these clinical facilitators demonstrated the ability to influence the prevailing atmosphere and the relationships between students and ward staff through exceptional communication skills. This then leads to the achievement of optimum learning outcomes for the students (Dunn and Burnett, 1995). Reciprocity of the learning experience has been highlighted in the works of Finn et al. (2000), where the interaction between the clients, students and staff of the health facility can combine to create a positive learning environment. The clinical facilitators identified the importance of sharing information with the students rather than a straight didactic type of interaction. This type of collaborative attitude is paramount to effective facilitation methods, and reinforces the students self-worth (Brookfield, 1986). The facilitators in this study highlighted the importance of including the patient in the students learning experience. Involving the patient in the learning experience for the student reinforces the stance that nursing as a human science mandates that patients should be cared for in a holistic manner (Sanford, 2000). Involving the patient, and attempting to discover the personal meaning attached to their experience of ill health exposes students to developing holistic understanding. The knowledge of which is embedded in the context of caring. The clinical facilitators felt a moral obligation identify appropriate clinical buddies for the students. Each participant verbalised the importance of budding the student with a Registered Nurse they felt would enhance learning opportunities as the student had so little time on placement. The facilitators also stated that the clinical buddy was in actual fact the most important person as the student spent the most time with them and not the facilitator. The behaviours that the facilitators identified correlate with a study conducted by Jackson and Mannix (2001) where the findings were grouped into helpful and non-helpful behaviours. Helpful behaviours were identified as; understanding and being friendly, showing interest and explaining, and unhelpful behaviours as actions such as ignoring and excluding the students (Jackson and Mannix, 2001). From these findings, it can be said that some Registered Nurses still find including student nurses as part of their normal
Facilitating undergraduate nurses clinical practicum work environment challenging. The facilitators in this study would try to avoid the impact of less positive clinical buddies on the learning outcomes for the students.
Conclusion/recommendations This study has brought to light how clinical facilitators facilitate learning in the clinical environment. Through the themes identified, learning in the clinical area is facilitated by the participants; knowing their own limitations, enabling the student to develop their own practice and self-awareness by either stepping in or stepping back, developing alliances with staff at the health care facility, acknowledging that the learning experience is reciprocal in nature and identifying the appropriate clinical care buddies for students. As stated previously there are many challenges to providing quality clinical education for undergraduate nurses in the changing context of health care. Two recommendations can be drawn from the findings of this study. Firstly, that clinical facilitators should be allocated to the same facility each placement to strengthen alliances formed. Secondly, that Registered Nurses be supported to up-skill in clinical teaching methods as the students spend the majority of their time with them on clinical practicum. The themes highlighted in this study certainly reflect the basic premise of facilitation in that it is a dynamic process in which the participants work together in an environment of mutual respect in order to learn.
References Andrews, M., Chilton, F., 2000. Student and mentor perceptions of mentoring effectiveness. Nurse Education Today 20, 555– 562. Benner, P., Benner, R., 1999. The clinical practice development model: making the clinical judgement, and collaborative work of nurses visible. In: Haag-Heitman, B. (Ed.), Clinical Practice Development: Using Novice to Expert Theory. Aspen, MD, pp. 17–41. Bowles, N., 1995. A critical appraisal of preceptorship. Nursing Standard 9 (45), 25–28. Brookfield, S., 1986. Understanding and Facilitating Adult Learning. Open University Press, Buckingham. Burrows, D., 1997. Facilitation: a concept analysis. Journal of Advanced Nursing 25, 396–404. Cahill, H., 1997. What should nurse teachers be doing? A preliminary study? Journal of Advanced Nursing 26 (1). Clare, J., 2002. AUTC Final Report. Curriculum, clinical education, recruitment, transition and retention in nursing. School of Nursing & Midwifery Flinders University, Adelaide. Clifford, C., 1996. Nurse teacher’s clinical work: a survey report. Journal of Advanced Nursing 23 (3), 603–611.
421 Cornes, D., 1998. Some thoughts on nurse education/service partnerships. Nurse Education Today 18, 655–662. Davies, E., Turner, C., Osborne, Y., 1999. Evaluating a clinical partnership model for undergraduate nursing students. Collegian: Journal of the Royal College of Nursing Australia 6 (2), 23–27. Dunn, S., Burnett, P., 1995. The development of a clinical learning environment scale. Journal of Advanced Nursing 22, 1166–1173. Ellis, R., Hogard, E., 2003. Two deficits and a solution? Explicating and evaluating clinical facilitation using consultative methods and multiple stakeholder perspectives. Learning in Health and Social Care 2 (1), 18–27. Finn, T., King, J., Thorburn, J., 2000. The educational needs of part time clinical facilitators. Contemporary Nurse 9 (2), 132–139. Fontana, A., Frey, J., 1998. Interviewing the art of science. In: Denzin, N., Lincoln, Y. (Eds.), Handbook of Qualitative Research. Sage, California, pp. 361–376. Gignac-Caille, A., Oermann, M., 2001. Student and faculty perceptions of effective clinical instructors in ADN programs. Journal of Nursing Education 40 (8), 347–353. Harvey, G., Loftus-Hills, A., Rycroft-Malone, J., Titchen, A., Kitson, A., McCormack, B., Seers, K., 2002. Getting evidence into practice: the role and function of facilitation. Journal of Advanced Nursing 37 (6), 577–588. Jackson, D., Mannix, J., 2001. Clinical nurses as teachers: insights from students in their first semester of study. Journal of Clinical Nursing 10 (2), 270–277. Kelly, D., Simpson, S., Brown, P., 2002. An action research project to evaluate the clinical practice facilitator role for junior nurses in acute care hospital setting. Journal of Clinical Nursing 11 (1), 90–98. Kotzabassaki, S., Panou, M., Dimou, F., Karabagli, A., Koutsopoulou, B., Ikonomou, U., 1997. Nursing students and faculty perceptions of the characteristics of ‘‘best’’ and worst’’ clinical; teachers: a replication study. Journal of Advanced Nursing 26 (4), 817–824. Kvale, S., 1996. Interviews: An Introduction to Qualitative Research Interviewing. Sage, London. Landmark, B., Hansen, G., Bjones, I., Bohler, A., 2003. Clinical supervision-factors defined by nurses as influential upon the development of competence and skills in supervision. Journal of Clinical Nursing 12, 834–841. Langridge, M., Hauck, Y., 1998. Perceptions of clinical role modelling: an exploration of nursing student’s experiential learning. Collegian: Journal of the Royal College of Nursing Australia 5 (4), 22–27. Lee, D., 1996. The clinical role of the nurse teacher: a review of the dispute. Journal of Advanced Nursing 23, 1127– 1134. Lee, W., Cholowski, K., Williams, A., 2002. Nursing students and clinical educators perceptions of characteristics of effective clinical educators in an Australian school of nursing. Journal of Advanced Nursing 39 (5), 412–420. Lo, R., Brown, R., 2000. A clinical teaching project: evaluation of the Mentor-arranged clinical practice by RN mentors. Collegian: Journal of the Royal College of Nursing Australia 7 (4), 8–10. Minichiello, V., Aroni, R., Timewell, E., Alexander, L., 1995. InDepth Interviewing. Longman, Sydney. National Review of Nursing Education Australia, 2002. Our Duty of Care. Department of Science Education and Training, Canberra. O’Brien, L., 2003. Phenomenology. In: Schneider, Z., Elliott, D., LoBiondo-Wood, G., Haber, J. (Eds.), Nursing Research
422 Methods, Critical Appraisal and Utilisation. Mosby, Sydney, pp. 193–203. Ohrling, K., Hallberg, I., 2000. The meaning of preceptorship: nurses lived experience of being a preceptor. Journal of Advanced Nursing 33 (4), 530–540. Phillips, N., Duke, M., 2001. The questioning skills of clinical teachers and preceptors: a comparative study. Journal of Advanced Nursing 33 (4), 523–529. Rowan, P., Barber, P., 2000. Clinical facilitators: a new way of working. Nursing Standard 14 (52), 35–38.
C. Dickson et al. Russell, G., 1999. Phenomenological research. In: Fain, J. (Ed.), Reading, Understanding and Applying Nursing Research. F.A. Davis, Philadelphia, pp. 167–183. Sanford, R., 2000. Caring through relation and dialogue: a nursing perspective for patient education. Advances in Nursing Science 22 (3), 1–15. Wellard, S., Rolls, C., Ferguson, S., 1995. Evaluating clinical educators: an employer’s perspective. Journal of Advanced Nursing 21 (4), 737–742.
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Facilitating undergraduate nurses clinical practicum: The lived experience of clinical facilitators Cathy Dickson
a,*
, Jane Walker
b,1
, Sharon Bourgeois
a,2
a
School of Nursing, Family and Community Health, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 1797, Australia b School of Clinical Sciences, Charles Sturt University, Locked Bag 588, Wagga Wagga, NSW 2678, Australia Accepted 25 November 2005
KEYWORDS
Summary Clinical practicum experience for undergraduate nurses remains undisputed as an essential component of any program. Exposure to the reality of professional practice and its integration of explicit, with tacit knowledge, is invaluable in producing skilled clinicians. Currently there are many issues that have arisen regarding clinical practice education for undergraduate nurses in Australia including; ongoing financial support and resourcing of clinical placements. Developing an understanding of these issues is central to the provision of quality clinical education. The aim of this study is to reveal dimensions of the lived experience of being a clinical facilitator, a popular model of nursing clinical education, to come to an understanding of how facilitation actually takes place in the clinical environment. The Hermeneutic phenomenological approach used in this study has brought to light five essential themes that elucidate the phenomena of facilitation. Those themes have been identified as; knowing your own limitations, employing the notion of stepping in or stepping back, developing alliances, acknowledging the reciprocity of the learning experience, and identifying appropriate clinical buddies. The recommendations from this study will have an impact on current issues and will inturn, influence the quality of clinical education for all stakeholders. c 2005 Elsevier Ltd. All rights reserved.
Undergraduate education; Lived experience; Clinical facilitation
Introduction * Corresponding author. Tel.: +61 02 45701904. E-mail addresses: [email protected] (C. Dickson), [email protected] (J. Walker), [email protected] (S. Bourgeois). 1 Tel.: +61 69332577. 2 Tel.: +61 02 45701904.
Clinical practice experience at the undergraduate level is essential for the development of competent Registered Nurses. Exposure to the reality of professional practice and its integration of explicit
0260-6917/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2005.11.012
Facilitating undergraduate nurses clinical practicum with tacit knowledge is invaluable in producing skilled clinicians. As the demand for clinical readiness of our under graduates increases, the provision of quality undergraduate clinical education has emerged as a national concern. In Australia these issues have been highlighted by the National Review of Nursing Education Australia (2002) and are currently the impetus for the formation of a national task force and other initiatives. The issues relate to types of models of clinical practice experience, resourcing clinical placements and the funding for these placements (National Review of Nurse Education, 2002). To date there are multiple models of clinical education utilised by the many tertiary institutions that offer undergraduate nursing education. There appears to be little consistency, and difficulty in evaluating the effectiveness and quality of clinical education models. A number of authors claim that the goals of effective clinical education are; skill acquisition, integration of theory with practice, application of problem solving skills, development of interpersonal skills, socialisation to the informal and formal norms of the profession, acclimatisation to the protocol and expectation of professional practice and exposure to the socio-political health care arena (Conway and McMillan, 2000; Hardy, 1990; Hutchings and Sanders, 2001; Jackson and Mannix, 2001; Mahat, 1998; Mundt, 1990; Severinsson, 1998 cited in Clare, 2002). Furthermore, clinical experience enables students to become proficient in the knowledge, skills, and attributes implicit in the Australian Nursing Council Incorporated (ANCI) competencies (Napthine, 1996; Nash, 1998 cited in Clare, 2002). A dynamic clinical environment, the changing face of health care and current trends in staffing, challenge the way in which these goals are attained for undergraduate students. The tertiary institution from which participants for this study were recruited uses several models. The predominant model is one clinically current Registered Nurse, employed on a sessional basis as a clinical facilitator appointed to a group of students allocated to a designated health facility. Usually facilitators are allocated on a ratio of 1:8 students. The students are commonly distributed throughout the health care facility, which requires the facilitator to relocate for supervision or assessment of individual student learning. Individual students are then ‘‘buddied’’ with a member of staff from the facility and they perform holistic patient care with their partner for that shift. The clinical facilitator supervises students learning experiences from a supernumery position (Finn et al., 2000) during that time.
417 The aim of this paper is to highlight how facilitation takes place under these circumstances in the current clinical environment.
Literature review The literature is replete with papers that have addressed the many relevant issues and controversies that have arisen as the demand for clinical ‘readiness’ of our under graduate nurses increases. Discussion has centred on various aspects of clinical education. For example differing models of clinical teaching are highlighted in works by Clifford (1996), Cahill (1997), Langridge and Hauck (1998), and Rowan and Barber (2000). Differing methods of educating students in the clinical setting and the campaign for excellence in undergraduate clinical education are examined in the works of Bowles (1995), Davies et al. (1999), Andrews and Chilton (2000), Lo and Brown (2000), and Kelly et al. (2002). Further to this discussion, a number of authors have centred on the differing perspectives and or requirements of the students (Kotzabassaki et al., 1997; Gignac-Caille and Oermann, 2001; Lee et al., 2002), the educators (Finn et al., 2000; Phillips and Duke, 2001) and other stakeholders (Wellard et al., 1995; Cornes, 1998; Ellis and Hogard, 2003) in the provision of clinical education. However, there is little documentation on how facilitation is achieved in the complex and changing environment of the clinical setting. A working definition of facilitation is offered by Harvey et al. (2002) as, a technique by which one person makes things easier for others. Harvey et al. (2002) go on to explicate the specific purpose of facilitation in practice based learning for health care as the co-creation of new knowledge through critical reflection and dialogue between learner and facilitator. Burrows (1997) offers a deeper examination in that ‘‘Facilitation is a goal oriented dynamic process in which participants work together in an atmosphere of mutual respect, in order to learn through critical reflection.’’ (p. 401)
Method The research philosophy The phenomenological philosophy is of particular importance to nursing research as it allows nurses
418 to examine questions related to phenomena experienced in health and illness (O’Brien, 2003). Given these underlying premises, Heideggerian phenomenology will form the basis of the underpinning philosophy for this study. At the turn of last century, phenomenology was founded as a philosophy by Husserl and extended by Heidegger to include existential concepts in order to understand human consciousness and experience (Kvale, 1996). When using this philosophy in the interview situation the interviewer seeks to find meanings in the life world of the interviewee (Kvale, 1996). Heideggerian investigation of meaning attempts to step beyond the obvious and identify the underlying essence of the experience through interpreting the practical understanding of human actions and experience (O’Brien, 2003).
Sample and setting Using a purposive technique a sample of 10 participants was chosen from the population of 164 clinical facilitators from a University in Sydney, NSW enrolling undergraduate student nurses. The sample selected was subject to inclusion criteria consisting of those facilitators who have been employed in the position for more than two consecutive semesters. Of the 10 eligible participants six responses were returned. Actual sample size was determined by data saturation or redundancy, which was defined as ‘‘The point when data collection is terminated because no new description and interpretations of the lived experience are forth coming from the study participants’’ (Russell, 1999, p. 168). Data saturation was reached after 5 in-depth semi-structured interviews were completed. Four females and one male participant were interviewed. The mean age of participants was 44 (32–51), and the average length of employment as a facilitator was 12 semesters (5–20).
Data collection This study was conducted using in depth semistructured interviews based on the technique of funnelling. This type of data collection requires a relationship between the interviewer and the participant. Without an established rapport based on trust it will be difficult to elicit the in depth kind of personal beliefs and views necessary to collect appropriate data (Minichiello et al., 1995). Rapport was established with the participants by engaging in general conversation before the interview. This is important as it allows the participant to feel comfortable and able to provide more detailed
C. Dickson et al. data (Fontana and Frey in Denzin and Lincoln, 1998). Funnelling allows general non-threatening questions to be asked and then, as the rapport develops, more in depth questions can be posed (Minichiello et al., 1995). Initial questions to be posed in these interviews are designed to help the participant to begin thinking about the phenomenon in general terms, and then focus on interpreting their own feelings about issues raised. Questioning began with ‘‘Can you please tell me what brought you to become a clinical facilitator?’’ and progressed to ‘‘Can you please tell me how you facilitate learning in the clinical environment?’’ This study was conducted for the course requirement in a Master of Clinical Nursing program. Ethics approval was obtained from the University the author was enrolled in, and approval sought for access to the clinical facilitators from their employer. All potential participants were contacted by post and sent a participant information letter explaining the study, and a consent form. After obtaining informed consent, interviews were scheduled at a convenient day and time for each participant. The interviews were audio taped and transcribed verbatim by the researcher. The duration of the five interviews ranged from 45 to 60 min.
Results Data analysis After reading and re-reading the entire transcripts to gain a sense of the whole, Giorgis’ thematic data analysis (Russell, 1999) was used to find meaning in the verbatim transcripts formed from the interviews (Minichiello et al., 1995). This method was chosen because of its suitability for use with a small number of participants who have lived the experience under study. From this thematic analysis five themes emerged from the data. These are: knowing your own limitations, employing the notion of stepping in or stepping back, developing alliances, acknowledging the reciprocity of the learning experience, and identifying appropriate clinical buddies. Theme 1. Knowing your own limitations For the participants in this study, this theme seemed to be a very important starting point for clinical education of students. That is facilitation of another’s learning begins with an understanding of the self. This becomes increasingly important
Facilitating undergraduate nurses clinical practicum when the clinical facilitator is expected to assist student learning outside his or her own speciality. ‘‘I know there are people within the hospital that can help them achieve a particular focus, they may have an area of expertise that I don’t because I’m not a walking encyclopaedia by any means.’’ Participant 2 Theme 2. Employing the notion of stepping in or stepping back All participants at one stage or another used this observational strategy during the course of the practicum. The facilitators felt that they could step back from direct student interaction and hand over control of care to the student. This notion was also employed when the student was interacting with their ‘‘buddy’’. The facilitator was in effect giving over the teachable moment to the buddy. ‘‘But I’ve learned to step back a little. So that’s been a little bit hard, like when we are sponging and showering I want to take over and say ‘‘Oh this is the way you do it’’. So I’ve had to say, ‘‘you do that’’. I make sure that they are safe and then I’ll just stand there’’. Participant 4 Stepping in was employed by the facilitator when there was a judgement made by them that the student’s action would in some way be detrimental to the patient. ‘‘. . .for example a couple of weeks ago I had to help the student put a catheter in. They had seen one done before. . . and in the process of doing it, it was a difficult situation and in the end I ended up helping to the point where I did most of it and um. . . they learnt in the sense of me doing it. . . with a commentary for example’’. Participant 3 Theme 3. Developing alliances As the facilitators may not be allocated to a clinical area or facility that they are normally employed in and, have students placed over a number of clinical areas in the same facility, a large part of their time is spent on forming alliances. These alliances allow the facilitators access to areas and resources that may usually be only available to staff, allow for smooth assimilation of the students and help address any difficulties the student or facilitator might come across. The resultant effect being extending the learning experience, or exposing the student to areas of interest. ‘‘I do see it as a public relations role, being nice to the staff, smoothing the way for the students’’. Participant 4
419 ‘‘My role is very diverse, its personalities, it’s the students, the staff the administration of the hospital. I mean I have to be very flexible. I’ve got to be very understanding and diplomatic. . . .That’s an enormous amount of work but I believe that continuity of care is very important to the students. . . .Building a rapport with them and the doctors and that is something I would have to do for each area’’. Participant 5
Theme 4. Acknowledging the reciprocity of the learning experience All of the participants viewed the experience of facilitation as more of a sharing than a straightforward didactic transmission of information. It was interesting to note that some of the facilitators included the patient in the sharing of learning. Whether this occurred as a direct or indirect effect of teaching the patient actually learnt something from the communication between the student and the facilitator. The facilitators encouraged the students to involve the patient in their care. Clearly, when the facilitator acknowledges the knowledge base of the student and the patient, learning in the clinical environment can be viewed as being triangular in nature. ‘‘As a facilitator it’s not like this person, the expert, just imparting knowledge. I very much believe that it is more of a mutual learning experience. . . at the bedside. . . I can’t say how often when were in there having a little teaching session. . . and the patients say ‘Oh that’s so interesting. . .’ Its me, the student nurse, and the patient at the bedside’’. Participant 1
Theme 5. Identifying appropriate clinical buddies Participants in this study discussed the importance of linking the student with a Registered Nurse who they felt would be supportive and encouraging. They were able to identify personal and professional characteristics that help them to decide if the student would benefit from the relationship. ‘‘. . .I guess when I first go to the ward I’m looking for attitudes. . . you know. . . ‘Oh no not students again!’ so that is someone who I definitely don’t want to buddy them with. . . so I’m trying to buddy them with someone who has a more positive attitude and more dynamic in um. . . being a professional’’. Participant 5
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Discussion The aim of this study was to uncover how facilitators actually facilitated learning in the clinical environment. The themes that were uncovered revealed the many facets of this role. The level of responsibility that the participants felt in relation to providing a quality experience for the students was overwhelming. Due to this, the level of commitment that these participants demonstrated should not be underestimated. Knowing your own limitations an examination of the self, an antecedent to facilitating clinical learning for the student, was extremely important to all the participants. Landmark et al.’s (2003) study supports this finding as their study also highlighted the fact that the quality of the experience was related to the professional self-confidence and self-awareness of the supervisor/facilitator. As a proponent of critical reflection Brookfield (1986), espouses that the development of the power of critical reflection is central to effective facilitation of learning. By acknowledging their own limitations and finding for more appropriate resources, the facilitator promotes a collaborative clinical learning environment. The notion of stepping in or stepping back as a teaching strategy relates to the facilitators skill in determining and managing aspects of learning in the clinical environment. When the facilitator deems that the student has a poor grasp of the clinical situation and that they need to step in, they are using their ‘‘skilled know how’’ (Benner and Benner, 1999, p. 25) in acting as a patient advocate. In relation to this Finn et al. (2000) discuss the unique situation clinical educators find themselves in whereby they have a three-pronged responsibility to the student, the client and the facility. By stepping back, the facilitator gives control of the experience to the student and hence assists the student develop a sense of self and, their own practice (Benner and Benner, 1999). A similar strategy was uncovered in Ohrling and Hallberg (2000) study but was referred to as nearness and distancing. This action results in decreasing the learner’s dependence on the facilitator, which is a hallmark of effective facilitation (Brookfield, 1986). Developing alliances in the clinical area has been uncovered as a theme in previous studies (Clifford, 1996; Ohrling and Hallberg, 2000; Ellis and Hogard, 2003). The participants in this study discussed spending a lot of time and effort in establishing relationships with relevant clinical staff that would prove to be conducive to the learning environment. Alexander’s study (cited in Lee, 1996) supports this finding by reporting that 50% of nurse teachers time
C. Dickson et al. was devoted to liaison. This effort not only enabled the creation of positive learning experiences, the essence of facilitation, but also widened their exposure to complementary areas of nursing practice. Dunn and Burnett (1995) list factors that commonly influence the learning environment that include interpersonal relationships, and atmosphere and attitudes. Clearly, these clinical facilitators demonstrated the ability to influence the prevailing atmosphere and the relationships between students and ward staff through exceptional communication skills. This then leads to the achievement of optimum learning outcomes for the students (Dunn and Burnett, 1995). Reciprocity of the learning experience has been highlighted in the works of Finn et al. (2000), where the interaction between the clients, students and staff of the health facility can combine to create a positive learning environment. The clinical facilitators identified the importance of sharing information with the students rather than a straight didactic type of interaction. This type of collaborative attitude is paramount to effective facilitation methods, and reinforces the students self-worth (Brookfield, 1986). The facilitators in this study highlighted the importance of including the patient in the students learning experience. Involving the patient in the learning experience for the student reinforces the stance that nursing as a human science mandates that patients should be cared for in a holistic manner (Sanford, 2000). Involving the patient, and attempting to discover the personal meaning attached to their experience of ill health exposes students to developing holistic understanding. The knowledge of which is embedded in the context of caring. The clinical facilitators felt a moral obligation identify appropriate clinical buddies for the students. Each participant verbalised the importance of budding the student with a Registered Nurse they felt would enhance learning opportunities as the student had so little time on placement. The facilitators also stated that the clinical buddy was in actual fact the most important person as the student spent the most time with them and not the facilitator. The behaviours that the facilitators identified correlate with a study conducted by Jackson and Mannix (2001) where the findings were grouped into helpful and non-helpful behaviours. Helpful behaviours were identified as; understanding and being friendly, showing interest and explaining, and unhelpful behaviours as actions such as ignoring and excluding the students (Jackson and Mannix, 2001). From these findings, it can be said that some Registered Nurses still find including student nurses as part of their normal
Facilitating undergraduate nurses clinical practicum work environment challenging. The facilitators in this study would try to avoid the impact of less positive clinical buddies on the learning outcomes for the students.
Conclusion/recommendations This study has brought to light how clinical facilitators facilitate learning in the clinical environment. Through the themes identified, learning in the clinical area is facilitated by the participants; knowing their own limitations, enabling the student to develop their own practice and self-awareness by either stepping in or stepping back, developing alliances with staff at the health care facility, acknowledging that the learning experience is reciprocal in nature and identifying the appropriate clinical care buddies for students. As stated previously there are many challenges to providing quality clinical education for undergraduate nurses in the changing context of health care. Two recommendations can be drawn from the findings of this study. Firstly, that clinical facilitators should be allocated to the same facility each placement to strengthen alliances formed. Secondly, that Registered Nurses be supported to up-skill in clinical teaching methods as the students spend the majority of their time with them on clinical practicum. The themes highlighted in this study certainly reflect the basic premise of facilitation in that it is a dynamic process in which the participants work together in an environment of mutual respect in order to learn.
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