- Email: [email protected]
RN as gatekeeper: Student understanding of the RN buddy role in clinical practice experience
Nurse Education in Practice (2006) 6, 389–396
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
RN as gatekeeper: Student understanding of the RN buddy role in clinical practice experience Jillian D. Brammer
*
School of Nursing and Midwifery, Griffith University, Logan Campus, University Drive, Meadowbrook, Queensland 4152, Australia Accepted 20 July 2006
KEYWORDS Registered nurse; Buddy role; Undergraduate student learning; Phenomenography
Summary Students may be informally buddied with registered nurses (RNs), during their clinical experience. This paper describes one component of a larger phenomenographic study that explored the qualitatively different ways students understand the RN buddy role during clinical experience and the implications of this understanding for student learning. The perception of the RN as gatekeeper was an unexpected finding and is the focus of this report. Phenomenography is a field of descriptive research concerned with the variation in ways people experience and understand similar phenomena. This approach was used to identify the variation in experience and understanding of students with buddy RNs. Individual semi-structured interviews were conducted with a purposive sample of 24 students from one university in Queensland, Australia. The two variations in understanding of the role discussed in this paper are: understanding as an expectation, and RN as gatekeeper: gatekeeping as access. The research highlights that the various ways RNs promote or block access for students influence the quality of the learning experience. Formal recognition of the complexity of the RN role is essential to ensure RNs have adequate preparation for their role with students. Crown Copyright c 2006 Published by Elsevier Ltd. All rights reserved. This article appears in a joint issue of the journals Nurse Education Today Vol. 26, No. 8, pp. 697–704 and Nurse Education in Practice Vol. 6, No. 6, pp. 389–396.
Introduction This report describes one component of a larger phenomenographic study that explored student understanding of the role of the registered nurse (RN) during clinical practice experience, to identify the variation in the ways students perceive the informal
* Tel.: +61 7 3382 1062; fax: +61 7 3382 1277. E-mail address: [email protected].
1471-5953/$ - see front matter Crown Copyright c 2006 Published by Elsevier Ltd. All rights reserved.
390 buddy RN role. One serendipitous finding was the notion of the RN as gatekeeper, a phenomenon that has not been discussed in depth in the literature, but is of major significance for successful learning experiences for students.
Background Clinical practice experience is a key component of all undergraduate nursing courses. The development of students as future professionals is influenced by opportunities to integrate theory with practice in clinical settings (Dalton, 2005). Gaining access to learning experiences and support contributes to make clinical practice experience a positive learning encounter. When access to learning experiences and opportunity for participation are limited, student confidence diminishes (Lo ¨fmark and Wikblad, 2001). In Australia, students may be buddied or paired informally with RNs for support during clinical experience when the clinical facilitator is not available. RNs have various ways of understanding this role and their understanding may differ from that of students (Midgley, 2006). The outcome is that students may have varied experiences that do not always prepare them adequately for their future role of graduate RN. While positive and negative aspects of students’ experiences with RNs during clinical experience in many different countries have been explored and published (Chow and Suen, 2001; Lo ¨fmark et al., 2001; Smith and Gray, 2001; Thornton and Chapman, 2000), little is known about the way students understand the role of the RN buddy. An earlier Australian phenomenographic study explored RNs’ understanding of their informal role in student learning during clinical practice (Brammer, in press). Analysis of data identified seven key elements that differentiate the ways that RNs understand their role. The intrinsic elements of differentiation are the way RNs structure learning, use strategic communication strategies, and are influenced by their own personal perspectives. Elements external to the RNs include the environment, their peer relations, and their relationship with the clinical facilitator. The interactions of all these elements influence the registered nursebuddy relationship. From the variation in the relationship of these elements, eight different ways of understanding the RN role were identified (Brammer, in press). These are RN as facilitator, teacher/coach, overseer/supervisor, peer support and role model, instructor, manager/foreman, authority or resis-
J.D. Brammer ter/dissenter. The focus of the RN role varies with each category and is characterised by decreasing involvement with students ranging from ‘facilitator’ to ‘resister/dissenter’ conceptions. The focus also varies from seeing students as future peers, to being work-load centred, own personal performance centred, or self-centred. The implications of these variations suggest that learning experiences for students buddied with RNs holding different conceptions may vary considerably. Students will have their own views about the RN buddy role which may conflict with that of the RN. The following research questions were used to guide this study: 1. What do students understand of the RN buddy role during clinical placement? 2. How do students perceive the RNs’ approach to their role with students? 3. What is the relationship between the understanding and the approach of the RN and student learning experience?
Research design Many of the studies of student experience that have used qualitative approaches have been broadly phenomenological, with a focus on the lived experience of students (Lo ¨fmark and Wikblad, 2001; Nolan, 1998; Spouse, 1998) and the essence of what is similar for students. Phenomenographic studies identify variation, and this approach was used to study RNs’ perceptions of their role with students (Brammer, in press). Phenomenography is an appropriate approach to identify the various ways students understand the RN buddy role, and will enable direct comparison to be made of the variation in findings of the RN buddy role between RNs and students. The aim of phenomenographic research is to study the experience of participants in order to understand the variation of the experience itself, and the variation of meaning of the experience for the participants (Marton, 1988). It is the relationship experienced between the phenomenon and the person that is the focus; in this study the relationship between students and the RN in a buddy role. The primary outcome of phenomenographic research is the identification of categories of description (Bowden, 2000). These evolve from the data collected, and are constructed by the researcher during analysis to describe the variation in the experience and the different ways these categories are understood by the participants (Marton, 1988).
RN as gatekeeper: Student understanding of the RN buddy role in clinical practice experience
Participants Students from all three years of an undergraduate nursing program participated in this study, to allow for maximum variation of experience and in recognition that students’ understanding of the RN role may be influenced by experience. The sample was purposive and students were volunteers. Students who were Enrolled Nurses were excluded from the study as their perceptions were expected to be different as a result of their previous nursing experience. Students who had repeated a clinical course of study were also excluded as this may have influenced their perception of the experience. Twenty-four students from each year level of the Bachelor of Nursing program at a metropolitan university in Queensland, Australia, participated; eight students from each year. Twenty participants are considered a reasonable number for a phenomenographic study (Trigwell, 2000) to provide breadth of data within a manageable timeframe. Twenty-four were selected to allow for attrition.
Ethical approval Ethical approval was obtained from the Human Research Ethics Committee at the university where students were enrolled. All participants gave written informed consent prior to interview, and were advised of their right to withdraw without prejudice at any time.
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interviews were digitally recorded with the permission of participants. Data were collected at the completion of a hospital clinical experience for each student. Students were asked to either describe both positive and negative clinical practice experiences with RNs, or, if they preferred, to describe their day when they were on clinical placement.
Data analysis Analysis of data obtained from interviews was used to identify the variation of understanding students hold, resulting in the categories of description which encapsulate the student ways of understanding the RN buddy role. Interviews were transcribed verbatim. There are no algorithms for the analysis of phenomenographic interviews, rather a series of iterations to distill the meaning by repeated reading of the transcripts (Bowden, 2000). The meaning units of all responses enable significant elements to be identified for each participant. The meaning statements are collated, grouping those with similar meaning, until all elements have been identified. Once the different ways of understanding had been allocated to categories, these were compared and contrasted with all the transcripts to identify the most meaningful conceptions that support each category (Marton, 1988). A detailed description of each category was developed using data from the transcripts to differentiate and explicate the uniqueness of each category.
Data collection Rigour Data for phenomenographic research are collected via individual face-to-face semi-structured interviews to determine the experience of the specific phenomenon (Dahlgren, 1993). While each interview commenced with the same question, subsequent questions were determined by the response of the participants to allow openness and variation in responses (Bowden, 2000). This was done to enable each participant to expand their dialogue about the theme in focus and to minimise interpretation by myself during analysis. I promoted expansion of points raised through the use of probe questions arising from the responses of each participant about their experience with RN buddies in clinical placement. The key elements identified in the earlier study (see Section Background) (Brammer, in press) were used as a framework when probing responses. Clarification of points expressed was sought when responses were not clear. The
Replication of categories of description as findings is not considered necessary, but that another researcher can recognise the categories of description once they have been identified (Marton, 1988). In phenomenographic research, a decision trail allows the reader to follow the steps taken during data collection, analysis and development of categories of description (Sandberg, 1997), demonstrating that the study has been implemented according to the philosophy that underpins the research approach (Gerber, 1993). Copies of transcripts were returned to each participant for verification of the content of the interview prior to analysis.
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Findings Categories of description Students encountered RNs with all the variations of understanding of the role identified in the eight categories from the first study. While these roles could be recognised within the experience of the participants, student understanding of the RN buddy role was seen from access to learning and support rather than a specific role style. The first category related to the general understanding students had about RNs and was expressed as expectations, varying according to year level: Understanding as an expectation. A second category was identified by all participants, that of RN as gatekeeper. Gatekeeping has two different meanings. A gate is a means of access, and a gatekeeper is one who is in charge of passage through a gate; or who monitors or oversees the actions of others (Dictionary.com, 2006). The second definition was what students expected. The first definition was the one they encountered, that of gaining access to learning experiences, particularly access to patient care. This category was identified as RN as gatekeeper: gatekeeping as access.
J.D. Brammer their expectations differed. Students wanted to be challenged to help them learn, with supervision but not close monitoring. Next year [3rdyear] I’ll expect them to be more of a shadowing influence. I would feel like I should have enough confidence to be able to try and do things, with them just offering advice. But I’d also expect them to allow me to try and do as much as I can. During the final semester students were looking to RNs to mentor them and provide support. There was an expectation that students would be treated as a team member of the ward. Most students expected RNs to acknowledge that students wanted to take initiative and allow student to do so. I’m going to be out in three months . . . I thought, ‘‘no I need to do, be totally on my own. Be confident and just having them in the background as a back up’’. Throughout all of these variations there are expectations of access to experience and support. These expectations are elaborated in the category of RN as gatekeeper: gatekeeping as access.
RN as gatekeeper: gatekeeping as access Understanding as an expectation All students expressed expectations of RN buddy behaviour that varied with time and experience. For the initial clinical experience, these varied from naivete ´ to negativity. There was a positive expectation initially that RNs would involve the student in everything, teaching and guiding them to ensure they did not make mistakes. One participant thought that
The key to a positive learning experience was gaining access to clinical experience. Students identified a variety of experiences that promoted, limited or blocked access. Students learnt very rapidly that they had to find strategies to counter the blocking tactics they identified in RNs. Most students recognised that their learning time in clinical practice was limited so they had to gain the best experience they could.
RNs would be excited students were coming and welcome us with open arms.
Gaining access
Negative expectations included being petrified as a result of hearing stories about RN negativity towards students. Another participant expected RNs to bully students and expect them to only do menial tasks. Being subordinate was another expectation identified. Students need help from RNs so it is important to please RNs and do what they say. By end of second year students recognised the need to take responsibility for their own learning. They expected RNs to allow them independence and advise them. Participants expected RNs to allow them to try to do as much as they could, with the student clarifying actions with the RN when
Gatekeeping starts with the arrival of students on a ward and the way RNs respond to student presence. The initial reception of RNs to students was seen as indicative of the ease of access to learning experiences and varied from welcoming to rejection. Willingness to buddy with a student was demonstrated in a variety of ways. When RNs volunteer, student expectation is positive. Students identified grudging acceptance as well as outright rejection. CN said ‘ok one of you have to have her’ and they all just went ‘No, not having her’. . . . And they, none of them wanted any of us. Two of us and it was like, ‘nup, no way’. So we’re just
RN as gatekeeper: Student understanding of the RN buddy role in clinical practice experience standing there going . . . ‘we kind of need someone!’ I looked at the CN as if ‘help us out here’ because, you know. . . And eventually one of them just said ‘Oh, I’ll have one’[negative tone]. Students made a point of introducing themselves regardless of the reception they received from RNs. Students made RNs aware of their learning needs either verbally or in writing. A smile from the student was identified as an important means of communication. By third year most students had learnt how to determine which RNs would be receptive to students. . . .your first day, . . . you get on the ward . . . walk around and suss people out and see how they work . . .What am I looking for? . . . their confidence level, are they talking to their patients, how they talk to their peers . . . are they friendly? Like you only have to listen in the tea room to see if they’re bitchy. Like . . . you [don’t] want to go with those ones and they’re dead give aways because they run every person down that’s not there, and . . . I just won’t buddy with them because you just wonder what on earth they’ll say about you when you’re not there. I look for I suppose just confidence and like if they’re interested in me to start with.
Promoting/limiting/blocking access The way the RNs communicated with students was indicative of whether access was likely to be promoted, limited or blocked. RNs communicated in a variety of ways such as demonstrating an interest in the student and their learning, by asking what they could or could not do, or wanted to achieve. Like the first night I got there this girl said, ‘‘Do you want to do a dressing?’’ And I went ‘‘Yes, I’ll come along.’’ Communication that limited or blocked access was more a lack of communication with the RN showing no interest in the student, sometimes not even speaking to the student. Some RNs asked students challenging questions that were confronting, interrogative and created fear. When access was being blocked by RNs students used different approaches to try to gain access. The strategies promoted responses from RNs and resulted in open dialogue. These included asking RNs questions to which the student already knew the answer, seeking an opportunity to engage and show elements of the self that the RN would identify with, thus reducing tension between the RN and student. Students called this ‘playing the game’. By creating an atmosphere of respect for
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the RN through acknowledging their knowledge and experience from which the student can learn, students were ‘stroking the RN ego’. The relationship with the RN influenced access. An invitation from the RN to participate, promoted access. Some RNs demonstrated this by taking an interest in the student as a person as well as their future as an RN. Seeing the student as part of the team also promoted access. Negative relationships that blocked access included RNs telling students to ‘‘get out of nursing while you can’’. Several students used the term ‘‘followed like a puppy dog’’ when the RN went off without including them. Another strategy RNs used was to keep the student busy doing menial tasks to avoid involvement with the student. RNs sometimes told students they were ‘‘doing OK’’ but told the clinical facilitator the opposite. So she was talking like [to the facilitator], ‘‘Oh you know, they don’t know what they are doing. They are not sure, and . . ., their practical work is not really professional.’’ But yes with us it was, ‘‘Everything is fine. Good work. Excellent.’’ Continuity of RN buddy over several days allowed a relationship and trust to develop between RN and student, increasing student confidence. When students used their initiative, were motivated and took a proactive approach to participation, RNs responded positively. Student appreciation for RN support strengthened the relationship. Students discussed differences and worked at developing a rapport with the RN buddy. . . .because I ask a million questions and the good ones will give you a million answers, and the bad ones will just sort of go ‘‘Oh, because it’s just the way we’ve done it. It’s just the way we do it’’. When access was being blocked, ensuring the RN knew students were conscious of taking up the RN’s time could have a positive effect. Focusing on what was of interest to the RN promoted access. When no strategies were successful, students sought experiences with other students and their RN buddies, and accepted that they should (hopefully) only have one day with that RN buddy. Students identified that experiences with RNs who block access can inhibit learning. [You get] one a placement that you get in a shift of the two weeks that you’re there. But they stick in your mind, because . . . it sort of throws you back a little bit . . . Or they’ll say things to you like, ‘‘You’re not doing right.’’ And it sort of dents your confidence a bit because you think you’re powering doing really well.
394 Access to learning experiences occurred when RNs asked students what they wanted to do or would like to do, and agreed to student participation when a student asked. She said ‘‘What out of this do you feel capable of doing . . . he has to have drains removed? And I would say I could do all . . . And she’d be like, ‘‘Right that’s your responsibility. . . . You come and get me at 12 o’clock we’re gonna take his drains out after he’s had his shower.’’ . . .and I felt like a real nurse. Blocked access resulted when students were sent to shower patients while RNs did activities that students wanted to do. Reasons for not including students (when a reason was forthcoming) included ‘‘There isn’t time’’; ‘‘You’re too slow’’ and ‘‘I’m too busy’’. Being polite, prepared and organised were strategies that promoted access to learning experiences. Students identified the need to be assertive and proactive about participation in learning activities, taking all opportunities offered. There was general acknowledgement that ‘you get out of prac what you put in’. Tactics for unblocking access included being one step ahead of what the RN was going to do, and being ready to identify readiness for participation before the RN could start to do it. . . .so just had to be one step ahead and say ‘‘I’m going to be doing those staples so you can come and watch me.’’ Or just going and get your trolley ready and come and say, ‘Ok I’m going to do these now would you like to come and watch me?’
Discussion Access to positive learning experiences is an essential component for developing as future registered nurses. Students want to be involved (Midgley, 2006). When access is not forthcoming, students spend valuable learning time using strategies to gain access to learning experiences (Nolan, 1998). Given the relevance students place on the initial reception from RNs, this can set the tone for the whole practical experience (Chesser-Smyth, 2005). Acknowledgement of the student with the need to feel valued (Midgley, 2006) is a key aspect of access. A negative reception, particularly for a student who views the clinical placement with trepidation, could undermine any confidence of the student. Dalton (2005) identifies the nursing domain as a daunting space, to which gaining ac-
J.D. Brammer cess may seem even more daunting when students are not feeling welcome (Myrick and Yonge, 2005). The differences in ways of communicating that can promote or block learning suggest that RNs may not be aware that the way they communicate influences students and what they can do (Thornton and Chapman, 2000). Students want of ‘‘fit in’’ and be accepted by RNs (Lo ¨fmark and Wikblad, 2001) and communication plays a key role in students gaining access to learning experiences. Communication contributes to the relationship students develop with RNs and whether students feel accepted (Dunn and Hansford, 1997). The relationship with the RN also influences access (Dunn et al., 1995). When RNs show confidence and interest in students, access is granted and student learning is enhanced (Thornton and Chapman, 2000). Although all students described negative experiences, they identified that these were occurring with less frequency. It is the outcome of the negative experience that has implications (Lo ¨fmark and Wikblad, 2001). When a student can learn from a negative experience, the learning can be positive. When the negative experience demoralises the student, the focus on learning is lost as the feelings of the student become paramount (Oermann, 1998). Students demonstrated that they are able to adopt strategies to counter negative experiences (Lo ¨fmark and Wikblad, 2001). The recognition that students taking responsibility for their own learning is positive although the rationale for the need for this proactivity needs to be addressed. Strategies like ‘‘staying one step ahead’’ of the RN, imply that students (at least in some instances) possess an ability to manage time and have a greater degree of awareness than the RNs in managing their environments (Lo ¨fmark and Wikblad, 2001). Students appear to be more aware of appropriate strategies and communication to facilitate access than some of the RNs they encounter.
Limitations of the study These findings are from one group of students in one Bachelor of Nursing program and may not be representative of students in other programs both here in Australia and overseas. While the number of participants is small, findings can be recognised by students as similar to their own experiences. Students were all volunteers and may differ from those who did not wish to participate.
RN as gatekeeper: Student understanding of the RN buddy role in clinical practice experience
Implications and conclusion Students of all levels have expectations that change over time. The expectations of second and third level students suggest that their expectations are not always met. All the expectations have elements of access and support. In reality, student learning experiences with RN buddies are tempered by RN gatekeeping. The easier the access, the more like the learning experience will be positive. A positive learning experience is one where the student has access to active participation in patient care experiences and is monitored and supervised adequately for their level of experience. Students are gaining some excellent learning experiences involved with the processes of gatekeeping (even if they are inadvertent)! Most of these findings have already been identified in the literature, but not necessarily from the perspective of access. Supporting student learning in clinical practice is a complex role. Many RNs appear unaware of the influences of their gatekeeping role on students. RNs are prepared as clinicians not teachers of students. They need to be supported through professional development to provide student-centred learning experiences for students. There is a need to raise the awareness of RNs about the importance for them to be actively supportive of student learning, providing access to learning experiences. Sharing findings such as those from this study with the clinicians on the floor, can assist RNs to recognise the existence of the gatekeeping role and the ways it can be addressed to support students as future peers. It may be difficult to help RNs acknowledge that blocking access to learning experiences may be contributing to the quality of new graduates and that their role is crucial. Demonstrating a need is often the first way to promote change. Preparation of students to help them recognise the ways RNs may approach students, can assist students to manage the differences between RNs in order to gain access to learning experiences, and make the most of any opportunities that arise. Sharing the change in perspective that students undergo as they gain more experience can assist other students to realise that their learning is a journey for which they need to take responsibility from the beginning. Motivation and interest are keys to unlock the gate and connect with the gatekeeper. It is time for the informal RN role with students to be formally acknowledged as complex and challenging for both RNs and students. It is one which needs adequate preparation and ongoing support to ensure that patients receive quality care at the
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same time that students are able to have positive learning experiences and develop professional competence.
Acknowledgements I wish to acknowledge Queensland Nursing Council for funding for this research, and the students who volunteered for this research project.
References Bowden, J., 2000. The nature of phenomenographic research. In: Bowden, J., Walsh, E. (Eds.), Phenomenography. RMIT University Press, Melbourne. Brammer, J., in press. A phenomenographic study of registered nurses’ understanding of their role in student learning – an Australian perspective. International Journal of Nursing Studies. doi:10.1016/j.ijnurstu.2005.11.004. Chesser-Smyth, P., 2005. The lived experiences of general student nurses on their first clinical placement: A phenomenological study. Nurse Education in Practice 5, 320–327. Chow, F., Suen, L., 2001. Clinical staff as mentors in preregistration undergraduate nursing education: students’ perceptions of the mentors’ roles and responsibilities. Nurse Education Today 21, 350–358. Dahlgren, L., 1993. Phenomenography: Video Recorded Interview. Queensland University of Technology, Brisbane. Dalton, L., 2005. Use of clinical space as an indicator of student nurses’ professional development and changing need for support. Nurse Education Today 25 (2), 126–131. Dictionary.com, 2006. http://dictionary.reference.com/ browse/gatekeeper. Dunn, S., Stockhausen, L., Thornton, R., Barnard, A., 1995. The relationship between clinical education format and selected student learning outcomes. Journal of Nursing Education 34 (1), 16–24. Dunn, S., Hansford, B., 1997. Undergraduate nursing students’ perceptions of their clinical learning environment. Journal of Advanced Nursing 25 (6), 1299–1306. Gerber, R., 1993. A sense of quality–qualitative research approaches for geographical education. In: Jager, H. (Ed.), Liber Amicorum Prof Niemz. Goethe University Press, Franfurt am Main, pp. 38–51. Lo ¨fmark, A., Carlsson, M., Wikblad, K., 2001. Student nurses’ perception of independence of supervision during clinical nursing practice. Journal of Clinical Nursing 10, 86–93. Lo ¨fmark, A., Wikblad, K., 2001. Facilitating and obstructing factors for development of learning in clinical practice: a student perspective. Journal of Advanced Nursing 34 (1), 43– 50. Marton, F., 1988. Phenomenography: exploring different conceptions of reality. In: Fetterman, D. (Ed.), Qualitative Approaches to Evaluation in Education: The Silent Revolution. Praeger, New York. Midgley, K., 2006. Pre-registration student nurses perception of the hospital-learning environment during clinical placements. Nurse Education Today 26, 338–345. Myrick, F., Yonge, O., 2005. Nursing Preceptorship: Connecting Practice and Education. Lippincott, Williams & Wilkins, Philadelphia.
396 Nolan, C., 1998. Learning on clinical placement: the experience of six Australian nursing students. Nurse Education Today 18, 622–629. Oermann, M., 1998. Differences in clinical experiences of ADN and BSN students. Journal of Nursing Education 37 (5), 197– 201. Sandberg, J., 1997. Are phenomenographic results reliable? Higher Education Research & Development 16 (2), 203– 212. Smith, P., Gray, B., 2001. Reassessing the concept of emotional labour in student nurse education: role of link lecturers and
J.D. Brammer mentors in a time of change. Nurse Education Today 21, 230– 237. Spouse, J., 1998. Scaffolding student learning in clinical practice. Nurse Education Today 18, 259–266. Thornton, R., Chapman, H., 2000. Student voice in curriculum making. Journal of Nursing Education 39 (3), 124– 132. Trigwell, K., 2000. A phenomenographic interview on phenomenography. In: Bowden, J., Walsh, E. (Eds.), Phenomenography. RMIT University Press, Melbourne.
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
RN as gatekeeper: Student understanding of the RN buddy role in clinical practice experience Jillian D. Brammer
*
School of Nursing and Midwifery, Griffith University, Logan Campus, University Drive, Meadowbrook, Queensland 4152, Australia Accepted 20 July 2006
KEYWORDS Registered nurse; Buddy role; Undergraduate student learning; Phenomenography
Summary Students may be informally buddied with registered nurses (RNs), during their clinical experience. This paper describes one component of a larger phenomenographic study that explored the qualitatively different ways students understand the RN buddy role during clinical experience and the implications of this understanding for student learning. The perception of the RN as gatekeeper was an unexpected finding and is the focus of this report. Phenomenography is a field of descriptive research concerned with the variation in ways people experience and understand similar phenomena. This approach was used to identify the variation in experience and understanding of students with buddy RNs. Individual semi-structured interviews were conducted with a purposive sample of 24 students from one university in Queensland, Australia. The two variations in understanding of the role discussed in this paper are: understanding as an expectation, and RN as gatekeeper: gatekeeping as access. The research highlights that the various ways RNs promote or block access for students influence the quality of the learning experience. Formal recognition of the complexity of the RN role is essential to ensure RNs have adequate preparation for their role with students. Crown Copyright c 2006 Published by Elsevier Ltd. All rights reserved. This article appears in a joint issue of the journals Nurse Education Today Vol. 26, No. 8, pp. 697–704 and Nurse Education in Practice Vol. 6, No. 6, pp. 389–396.
Introduction This report describes one component of a larger phenomenographic study that explored student understanding of the role of the registered nurse (RN) during clinical practice experience, to identify the variation in the ways students perceive the informal
* Tel.: +61 7 3382 1062; fax: +61 7 3382 1277. E-mail address: [email protected].
1471-5953/$ - see front matter Crown Copyright c 2006 Published by Elsevier Ltd. All rights reserved.
390 buddy RN role. One serendipitous finding was the notion of the RN as gatekeeper, a phenomenon that has not been discussed in depth in the literature, but is of major significance for successful learning experiences for students.
Background Clinical practice experience is a key component of all undergraduate nursing courses. The development of students as future professionals is influenced by opportunities to integrate theory with practice in clinical settings (Dalton, 2005). Gaining access to learning experiences and support contributes to make clinical practice experience a positive learning encounter. When access to learning experiences and opportunity for participation are limited, student confidence diminishes (Lo ¨fmark and Wikblad, 2001). In Australia, students may be buddied or paired informally with RNs for support during clinical experience when the clinical facilitator is not available. RNs have various ways of understanding this role and their understanding may differ from that of students (Midgley, 2006). The outcome is that students may have varied experiences that do not always prepare them adequately for their future role of graduate RN. While positive and negative aspects of students’ experiences with RNs during clinical experience in many different countries have been explored and published (Chow and Suen, 2001; Lo ¨fmark et al., 2001; Smith and Gray, 2001; Thornton and Chapman, 2000), little is known about the way students understand the role of the RN buddy. An earlier Australian phenomenographic study explored RNs’ understanding of their informal role in student learning during clinical practice (Brammer, in press). Analysis of data identified seven key elements that differentiate the ways that RNs understand their role. The intrinsic elements of differentiation are the way RNs structure learning, use strategic communication strategies, and are influenced by their own personal perspectives. Elements external to the RNs include the environment, their peer relations, and their relationship with the clinical facilitator. The interactions of all these elements influence the registered nursebuddy relationship. From the variation in the relationship of these elements, eight different ways of understanding the RN role were identified (Brammer, in press). These are RN as facilitator, teacher/coach, overseer/supervisor, peer support and role model, instructor, manager/foreman, authority or resis-
J.D. Brammer ter/dissenter. The focus of the RN role varies with each category and is characterised by decreasing involvement with students ranging from ‘facilitator’ to ‘resister/dissenter’ conceptions. The focus also varies from seeing students as future peers, to being work-load centred, own personal performance centred, or self-centred. The implications of these variations suggest that learning experiences for students buddied with RNs holding different conceptions may vary considerably. Students will have their own views about the RN buddy role which may conflict with that of the RN. The following research questions were used to guide this study: 1. What do students understand of the RN buddy role during clinical placement? 2. How do students perceive the RNs’ approach to their role with students? 3. What is the relationship between the understanding and the approach of the RN and student learning experience?
Research design Many of the studies of student experience that have used qualitative approaches have been broadly phenomenological, with a focus on the lived experience of students (Lo ¨fmark and Wikblad, 2001; Nolan, 1998; Spouse, 1998) and the essence of what is similar for students. Phenomenographic studies identify variation, and this approach was used to study RNs’ perceptions of their role with students (Brammer, in press). Phenomenography is an appropriate approach to identify the various ways students understand the RN buddy role, and will enable direct comparison to be made of the variation in findings of the RN buddy role between RNs and students. The aim of phenomenographic research is to study the experience of participants in order to understand the variation of the experience itself, and the variation of meaning of the experience for the participants (Marton, 1988). It is the relationship experienced between the phenomenon and the person that is the focus; in this study the relationship between students and the RN in a buddy role. The primary outcome of phenomenographic research is the identification of categories of description (Bowden, 2000). These evolve from the data collected, and are constructed by the researcher during analysis to describe the variation in the experience and the different ways these categories are understood by the participants (Marton, 1988).
RN as gatekeeper: Student understanding of the RN buddy role in clinical practice experience
Participants Students from all three years of an undergraduate nursing program participated in this study, to allow for maximum variation of experience and in recognition that students’ understanding of the RN role may be influenced by experience. The sample was purposive and students were volunteers. Students who were Enrolled Nurses were excluded from the study as their perceptions were expected to be different as a result of their previous nursing experience. Students who had repeated a clinical course of study were also excluded as this may have influenced their perception of the experience. Twenty-four students from each year level of the Bachelor of Nursing program at a metropolitan university in Queensland, Australia, participated; eight students from each year. Twenty participants are considered a reasonable number for a phenomenographic study (Trigwell, 2000) to provide breadth of data within a manageable timeframe. Twenty-four were selected to allow for attrition.
Ethical approval Ethical approval was obtained from the Human Research Ethics Committee at the university where students were enrolled. All participants gave written informed consent prior to interview, and were advised of their right to withdraw without prejudice at any time.
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interviews were digitally recorded with the permission of participants. Data were collected at the completion of a hospital clinical experience for each student. Students were asked to either describe both positive and negative clinical practice experiences with RNs, or, if they preferred, to describe their day when they were on clinical placement.
Data analysis Analysis of data obtained from interviews was used to identify the variation of understanding students hold, resulting in the categories of description which encapsulate the student ways of understanding the RN buddy role. Interviews were transcribed verbatim. There are no algorithms for the analysis of phenomenographic interviews, rather a series of iterations to distill the meaning by repeated reading of the transcripts (Bowden, 2000). The meaning units of all responses enable significant elements to be identified for each participant. The meaning statements are collated, grouping those with similar meaning, until all elements have been identified. Once the different ways of understanding had been allocated to categories, these were compared and contrasted with all the transcripts to identify the most meaningful conceptions that support each category (Marton, 1988). A detailed description of each category was developed using data from the transcripts to differentiate and explicate the uniqueness of each category.
Data collection Rigour Data for phenomenographic research are collected via individual face-to-face semi-structured interviews to determine the experience of the specific phenomenon (Dahlgren, 1993). While each interview commenced with the same question, subsequent questions were determined by the response of the participants to allow openness and variation in responses (Bowden, 2000). This was done to enable each participant to expand their dialogue about the theme in focus and to minimise interpretation by myself during analysis. I promoted expansion of points raised through the use of probe questions arising from the responses of each participant about their experience with RN buddies in clinical placement. The key elements identified in the earlier study (see Section Background) (Brammer, in press) were used as a framework when probing responses. Clarification of points expressed was sought when responses were not clear. The
Replication of categories of description as findings is not considered necessary, but that another researcher can recognise the categories of description once they have been identified (Marton, 1988). In phenomenographic research, a decision trail allows the reader to follow the steps taken during data collection, analysis and development of categories of description (Sandberg, 1997), demonstrating that the study has been implemented according to the philosophy that underpins the research approach (Gerber, 1993). Copies of transcripts were returned to each participant for verification of the content of the interview prior to analysis.
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Findings Categories of description Students encountered RNs with all the variations of understanding of the role identified in the eight categories from the first study. While these roles could be recognised within the experience of the participants, student understanding of the RN buddy role was seen from access to learning and support rather than a specific role style. The first category related to the general understanding students had about RNs and was expressed as expectations, varying according to year level: Understanding as an expectation. A second category was identified by all participants, that of RN as gatekeeper. Gatekeeping has two different meanings. A gate is a means of access, and a gatekeeper is one who is in charge of passage through a gate; or who monitors or oversees the actions of others (Dictionary.com, 2006). The second definition was what students expected. The first definition was the one they encountered, that of gaining access to learning experiences, particularly access to patient care. This category was identified as RN as gatekeeper: gatekeeping as access.
J.D. Brammer their expectations differed. Students wanted to be challenged to help them learn, with supervision but not close monitoring. Next year [3rdyear] I’ll expect them to be more of a shadowing influence. I would feel like I should have enough confidence to be able to try and do things, with them just offering advice. But I’d also expect them to allow me to try and do as much as I can. During the final semester students were looking to RNs to mentor them and provide support. There was an expectation that students would be treated as a team member of the ward. Most students expected RNs to acknowledge that students wanted to take initiative and allow student to do so. I’m going to be out in three months . . . I thought, ‘‘no I need to do, be totally on my own. Be confident and just having them in the background as a back up’’. Throughout all of these variations there are expectations of access to experience and support. These expectations are elaborated in the category of RN as gatekeeper: gatekeeping as access.
RN as gatekeeper: gatekeeping as access Understanding as an expectation All students expressed expectations of RN buddy behaviour that varied with time and experience. For the initial clinical experience, these varied from naivete ´ to negativity. There was a positive expectation initially that RNs would involve the student in everything, teaching and guiding them to ensure they did not make mistakes. One participant thought that
The key to a positive learning experience was gaining access to clinical experience. Students identified a variety of experiences that promoted, limited or blocked access. Students learnt very rapidly that they had to find strategies to counter the blocking tactics they identified in RNs. Most students recognised that their learning time in clinical practice was limited so they had to gain the best experience they could.
RNs would be excited students were coming and welcome us with open arms.
Gaining access
Negative expectations included being petrified as a result of hearing stories about RN negativity towards students. Another participant expected RNs to bully students and expect them to only do menial tasks. Being subordinate was another expectation identified. Students need help from RNs so it is important to please RNs and do what they say. By end of second year students recognised the need to take responsibility for their own learning. They expected RNs to allow them independence and advise them. Participants expected RNs to allow them to try to do as much as they could, with the student clarifying actions with the RN when
Gatekeeping starts with the arrival of students on a ward and the way RNs respond to student presence. The initial reception of RNs to students was seen as indicative of the ease of access to learning experiences and varied from welcoming to rejection. Willingness to buddy with a student was demonstrated in a variety of ways. When RNs volunteer, student expectation is positive. Students identified grudging acceptance as well as outright rejection. CN said ‘ok one of you have to have her’ and they all just went ‘No, not having her’. . . . And they, none of them wanted any of us. Two of us and it was like, ‘nup, no way’. So we’re just
RN as gatekeeper: Student understanding of the RN buddy role in clinical practice experience standing there going . . . ‘we kind of need someone!’ I looked at the CN as if ‘help us out here’ because, you know. . . And eventually one of them just said ‘Oh, I’ll have one’[negative tone]. Students made a point of introducing themselves regardless of the reception they received from RNs. Students made RNs aware of their learning needs either verbally or in writing. A smile from the student was identified as an important means of communication. By third year most students had learnt how to determine which RNs would be receptive to students. . . .your first day, . . . you get on the ward . . . walk around and suss people out and see how they work . . .What am I looking for? . . . their confidence level, are they talking to their patients, how they talk to their peers . . . are they friendly? Like you only have to listen in the tea room to see if they’re bitchy. Like . . . you [don’t] want to go with those ones and they’re dead give aways because they run every person down that’s not there, and . . . I just won’t buddy with them because you just wonder what on earth they’ll say about you when you’re not there. I look for I suppose just confidence and like if they’re interested in me to start with.
Promoting/limiting/blocking access The way the RNs communicated with students was indicative of whether access was likely to be promoted, limited or blocked. RNs communicated in a variety of ways such as demonstrating an interest in the student and their learning, by asking what they could or could not do, or wanted to achieve. Like the first night I got there this girl said, ‘‘Do you want to do a dressing?’’ And I went ‘‘Yes, I’ll come along.’’ Communication that limited or blocked access was more a lack of communication with the RN showing no interest in the student, sometimes not even speaking to the student. Some RNs asked students challenging questions that were confronting, interrogative and created fear. When access was being blocked by RNs students used different approaches to try to gain access. The strategies promoted responses from RNs and resulted in open dialogue. These included asking RNs questions to which the student already knew the answer, seeking an opportunity to engage and show elements of the self that the RN would identify with, thus reducing tension between the RN and student. Students called this ‘playing the game’. By creating an atmosphere of respect for
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the RN through acknowledging their knowledge and experience from which the student can learn, students were ‘stroking the RN ego’. The relationship with the RN influenced access. An invitation from the RN to participate, promoted access. Some RNs demonstrated this by taking an interest in the student as a person as well as their future as an RN. Seeing the student as part of the team also promoted access. Negative relationships that blocked access included RNs telling students to ‘‘get out of nursing while you can’’. Several students used the term ‘‘followed like a puppy dog’’ when the RN went off without including them. Another strategy RNs used was to keep the student busy doing menial tasks to avoid involvement with the student. RNs sometimes told students they were ‘‘doing OK’’ but told the clinical facilitator the opposite. So she was talking like [to the facilitator], ‘‘Oh you know, they don’t know what they are doing. They are not sure, and . . ., their practical work is not really professional.’’ But yes with us it was, ‘‘Everything is fine. Good work. Excellent.’’ Continuity of RN buddy over several days allowed a relationship and trust to develop between RN and student, increasing student confidence. When students used their initiative, were motivated and took a proactive approach to participation, RNs responded positively. Student appreciation for RN support strengthened the relationship. Students discussed differences and worked at developing a rapport with the RN buddy. . . .because I ask a million questions and the good ones will give you a million answers, and the bad ones will just sort of go ‘‘Oh, because it’s just the way we’ve done it. It’s just the way we do it’’. When access was being blocked, ensuring the RN knew students were conscious of taking up the RN’s time could have a positive effect. Focusing on what was of interest to the RN promoted access. When no strategies were successful, students sought experiences with other students and their RN buddies, and accepted that they should (hopefully) only have one day with that RN buddy. Students identified that experiences with RNs who block access can inhibit learning. [You get] one a placement that you get in a shift of the two weeks that you’re there. But they stick in your mind, because . . . it sort of throws you back a little bit . . . Or they’ll say things to you like, ‘‘You’re not doing right.’’ And it sort of dents your confidence a bit because you think you’re powering doing really well.
394 Access to learning experiences occurred when RNs asked students what they wanted to do or would like to do, and agreed to student participation when a student asked. She said ‘‘What out of this do you feel capable of doing . . . he has to have drains removed? And I would say I could do all . . . And she’d be like, ‘‘Right that’s your responsibility. . . . You come and get me at 12 o’clock we’re gonna take his drains out after he’s had his shower.’’ . . .and I felt like a real nurse. Blocked access resulted when students were sent to shower patients while RNs did activities that students wanted to do. Reasons for not including students (when a reason was forthcoming) included ‘‘There isn’t time’’; ‘‘You’re too slow’’ and ‘‘I’m too busy’’. Being polite, prepared and organised were strategies that promoted access to learning experiences. Students identified the need to be assertive and proactive about participation in learning activities, taking all opportunities offered. There was general acknowledgement that ‘you get out of prac what you put in’. Tactics for unblocking access included being one step ahead of what the RN was going to do, and being ready to identify readiness for participation before the RN could start to do it. . . .so just had to be one step ahead and say ‘‘I’m going to be doing those staples so you can come and watch me.’’ Or just going and get your trolley ready and come and say, ‘Ok I’m going to do these now would you like to come and watch me?’
Discussion Access to positive learning experiences is an essential component for developing as future registered nurses. Students want to be involved (Midgley, 2006). When access is not forthcoming, students spend valuable learning time using strategies to gain access to learning experiences (Nolan, 1998). Given the relevance students place on the initial reception from RNs, this can set the tone for the whole practical experience (Chesser-Smyth, 2005). Acknowledgement of the student with the need to feel valued (Midgley, 2006) is a key aspect of access. A negative reception, particularly for a student who views the clinical placement with trepidation, could undermine any confidence of the student. Dalton (2005) identifies the nursing domain as a daunting space, to which gaining ac-
J.D. Brammer cess may seem even more daunting when students are not feeling welcome (Myrick and Yonge, 2005). The differences in ways of communicating that can promote or block learning suggest that RNs may not be aware that the way they communicate influences students and what they can do (Thornton and Chapman, 2000). Students want of ‘‘fit in’’ and be accepted by RNs (Lo ¨fmark and Wikblad, 2001) and communication plays a key role in students gaining access to learning experiences. Communication contributes to the relationship students develop with RNs and whether students feel accepted (Dunn and Hansford, 1997). The relationship with the RN also influences access (Dunn et al., 1995). When RNs show confidence and interest in students, access is granted and student learning is enhanced (Thornton and Chapman, 2000). Although all students described negative experiences, they identified that these were occurring with less frequency. It is the outcome of the negative experience that has implications (Lo ¨fmark and Wikblad, 2001). When a student can learn from a negative experience, the learning can be positive. When the negative experience demoralises the student, the focus on learning is lost as the feelings of the student become paramount (Oermann, 1998). Students demonstrated that they are able to adopt strategies to counter negative experiences (Lo ¨fmark and Wikblad, 2001). The recognition that students taking responsibility for their own learning is positive although the rationale for the need for this proactivity needs to be addressed. Strategies like ‘‘staying one step ahead’’ of the RN, imply that students (at least in some instances) possess an ability to manage time and have a greater degree of awareness than the RNs in managing their environments (Lo ¨fmark and Wikblad, 2001). Students appear to be more aware of appropriate strategies and communication to facilitate access than some of the RNs they encounter.
Limitations of the study These findings are from one group of students in one Bachelor of Nursing program and may not be representative of students in other programs both here in Australia and overseas. While the number of participants is small, findings can be recognised by students as similar to their own experiences. Students were all volunteers and may differ from those who did not wish to participate.
RN as gatekeeper: Student understanding of the RN buddy role in clinical practice experience
Implications and conclusion Students of all levels have expectations that change over time. The expectations of second and third level students suggest that their expectations are not always met. All the expectations have elements of access and support. In reality, student learning experiences with RN buddies are tempered by RN gatekeeping. The easier the access, the more like the learning experience will be positive. A positive learning experience is one where the student has access to active participation in patient care experiences and is monitored and supervised adequately for their level of experience. Students are gaining some excellent learning experiences involved with the processes of gatekeeping (even if they are inadvertent)! Most of these findings have already been identified in the literature, but not necessarily from the perspective of access. Supporting student learning in clinical practice is a complex role. Many RNs appear unaware of the influences of their gatekeeping role on students. RNs are prepared as clinicians not teachers of students. They need to be supported through professional development to provide student-centred learning experiences for students. There is a need to raise the awareness of RNs about the importance for them to be actively supportive of student learning, providing access to learning experiences. Sharing findings such as those from this study with the clinicians on the floor, can assist RNs to recognise the existence of the gatekeeping role and the ways it can be addressed to support students as future peers. It may be difficult to help RNs acknowledge that blocking access to learning experiences may be contributing to the quality of new graduates and that their role is crucial. Demonstrating a need is often the first way to promote change. Preparation of students to help them recognise the ways RNs may approach students, can assist students to manage the differences between RNs in order to gain access to learning experiences, and make the most of any opportunities that arise. Sharing the change in perspective that students undergo as they gain more experience can assist other students to realise that their learning is a journey for which they need to take responsibility from the beginning. Motivation and interest are keys to unlock the gate and connect with the gatekeeper. It is time for the informal RN role with students to be formally acknowledged as complex and challenging for both RNs and students. It is one which needs adequate preparation and ongoing support to ensure that patients receive quality care at the
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same time that students are able to have positive learning experiences and develop professional competence.
Acknowledgements I wish to acknowledge Queensland Nursing Council for funding for this research, and the students who volunteered for this research project.
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