'Don't rock the boat': Nursing students' experiences of conformity and compliance

Clinical teaching and learning within a preceptorship model in an acute care hospital in Ireland; a qualitative study

BACKGROUND

A preceptorship model of clinical teaching was introduced to support the new all-graduate nurse education programme in Ireland in 2002. Little is known about how this model impacts upon the pedagogical practices of the preceptor or student learning in clinical practice leading to question what constitutes effective teaching and learning in clinical practice at undergraduate level.

AIM

This study aimed to explore the clinical teaching and learning within a preceptorship model in an acute care hospital in Ireland and identify when best practice, based on current theoretical professional and educational principles occurred.

METHOD

A qualitative research study of a purposively selected sample of 13 students and 13 preceptors, working together in four clinical areas in one hospital in Ireland. Methods were semi-structured interviews, analysed thematically, complemented by documentary analysis relating to the teaching and assessment of the students. Ethical approval was gained from the hospital's Ethics Committee.

FINDINGS

Preceptor-student contact time within an empowering student-preceptor learning relationship was the foundation of effective teaching and learning and assessment. Dialoguing and talking through practice enhanced the students' knowledge and understanding, while the ability of the preceptor to ask higher order questions promoted the students' clinical reasoning and problem solving skills. Insufficient time to teach, and an over reliance on students' ability to participate in and contribute to practice with minimal guidance were found to negatively impact students' learning.

CONCLUSIONS & IMPLICATIONS

Concepts such as cognitive apprenticeship, scaffolding and learning in communities of practice can be helpful in understanding the processes entailed in preceptorship. Preceptors need extensive educational preparation and support to ensure they have the pedagogical competencies necessary to provide the cognitive teaching techniques that foster professional performance and clinical reasoning. National competency based standards for preceptor preparation should be developed.

Self-reported confidence in patient safety knowledge among Australian undergraduate nursing students: A multi-site cross-sectional survey study

BACKGROUND

Patient safety is critical to the provision of quality health care and thus is an essential component of nurse education.

OBJECTIVE

To describe first, second and third year Australian undergraduate nursing students' confidence in patient safety knowledge acquired in the classroom and clinical settings across the three years of the undergraduate nursing program.

DESIGN

A cross-sectional online survey conducted in 2015.

SETTING

Seven Australian universities with campuses across three states (Queensland, New South Wales, South Australia).

PARTICIPANTS

A total of 1319 Australian undergraduate nursing students.

METHODS

Participants were surveyed using the 31-item Health Professional Education in Patient Safety Survey (H-PEPSS). Descriptive statistics summarised the sample and survey responses. Paired t-tests, ANOVA and generalized-estimating-equations models were used to compare responses across learning settings (classroom and clinical), and year of nursing course.

RESULTS

Participants were most confident in their learning of clinical safety skills and least confident in learning about the sociocultural dimensions of working in teams with other health professionals, managing safety risks and understanding human and environmental factors. Only 59% of students felt confident they could approach someone engaging in unsafe practice, 75% of students agreed it was difficult to question the decisions or actions of those with more authority, and 78% were concerned they would face disciplinary action if they made a serious error. One patient safety subscale, Recognising and responding to remove immediate safety risks, was rated significantly higher by third year nursing students than by first and second year students. Two broader aspects of patient safety scales, Consistency in how patient safety issues are dealt with by different preceptors, and System aspects of patient safety are well covered in our program, were rated significantly higher by first year nursing students than by second and third year students. One scale, Understanding that reporting adverse events and close calls can lead to change and can reduce recurrence of events, was rated significantly higher by third year students than first and second year students.

CONCLUSIONS

In order are to achieve meaningful improvements in patient safety, and create harm free environments for patients, it is crucial that nursing students develop confidence communicating with others to improve patient safety, particularly in the areas of challenging poor practice, and recognising, responding to and disclosing adverse events, including errors and near misses.

Nursing and midwifery students' encounters with poor clinical practice: A systematic review

The aim of this paper was to systematically review evidence about nursing and midwifery students' encounters with poor clinical care. We undertook a systematic review of English language empirical research using multiple databases from inception to April 2016. Hand searching was also undertaken. Included papers contained accounts of empirical research which reported on students' encounters with poor care. These were quality-assessed, information was extracted into tables, and study results were synthesized using thematic analysis. N = 14 papers met inclusion criteria; study quality was moderate to good. Study synthesis revealed four themes: i) encounters with poor practice: students encounter poor practice that is likely to be worthy of professional sanction; ii) while intention to report is high in hypothetical scenarios, this appears not always to translate to actual practice; iii) a range of influencing factors impact the likelihood of reporting; iv) the consequences of encountering and subsequently reporting poor practice appeared to have a lasting effect on students. Research is required to determine the frequency and nature of students' encounters with poor care, when and where they encounter it, how to increase the likelihood that they will report it, and how they can be supported in doing so.

Factors Affecting the Belongingness Sense of Undergraduate Nursing Students towards Clinical Setting: A Qualitative Study

Introduction: One of the most important needs of the students to work reliably in the clinical setting is the feeling of belongingness. Understanding and recognizing such a distinguishing feature among students can reduce their stress and tension. The current research aimed at studying the experiences of belongingness among nursing students in clinical settings.

Methods: In this conventional content analysis study, 12 nursing students were selected from Lorestan University of Medical Sciences by purposive method. In-depth interviews were employed to collect data. All interviews were recorded and transcribed for analyses. Data collection and analysis were carried out at the same time.

Results: The nature of belongingness with respect to clinical setting was expressed and classified in five themes and 11 subthemes. Five concepts (themes), which constituted the nature of nursing students’ experiences, were as follows: moving in the direction of evolvement, attention to human and ethical values, professional integrity, achieving inner satisfaction, and the environment conformity with learner.

Conclusion: The issue of belongingness and its promotion are of utmost importance. The clinical staff, including head nurses and nurses, must perform their roles properly in providing supportive and facilitative clinical environment, positive and constructive interactions, and professional development contexts for students, so that they feel being accepted and valued.

Rocking the boat - nursing students' stories of moral courage: A qualitative descriptive study

AIM

This paper profiles a qualitative study that examined how undergraduate nursing students demonstrate moral courage when confronted with clinical situations that negatively impact the quality of patient care and/or patient experience and the factors that encouraged or inhibited their willingness to speak up when they identified poor practice.

BACKGROUND

Clinical placements are an essential component of nursing programmes. However, placements are a reported source of stress for students, with many witnessing, or feeling compelled to participate in, poor practice. In these instances, nursing students require the moral courage to raise concerns in order to protect patient safety and dignity.

METHODS

This was a qualitative descriptive study. Nine nursing students and one nursing graduate from one semi-metropolitan university in Australia were interviewed and the data were thematically analysed.

FINDINGS

Four key themes emerged: (1) patient advocate identity, which had two sub-themes of knowing one's own moral code and previous life experiences; (2) consequences to the patient and to the participant; (3) the impact of key individuals; and (4) picking your battles.

CONCLUSION

This study demonstrates the importance of undergraduate nursing students identifying as patient advocates, the multitude of consequences students face when questioning the practice of a registered nurse, and the influence supervising nurses and clinical facilitators have on a student's decisions to intervene to protect patient safety. Further research is required to examine the factors, both intrinsic and extrinsic, that influence nursing students' moral courage and their decisions to intervene when poor practice is witnessed.

A survey-based study of factors that motivate nurses to protect the privacy of electronic medical records

BACKGROUND

The purpose of this study is to investigate factors that motivate nurses to protect privacy in electronic medical records, based on the Decomposed Theory of Planned Behavior.

METHODS

This cross-sectional study used questionnaires to collect data from nurses in a large tertiary care military hospital in Taiwan.

RESULTS

The three hundred two (302) valid questionnaires returned resulted in a response rate of 63.7 %. Structural equation modeling identified that the factors of attitude, subjective norm, and perceived behavioral control of the nurses significantly predicted the nurses' intention to protect the privacy of electronic medical records. Further, perceived usefulness and compatibility, peer and superior influence, self-efficacy and facilitating conditions, respectively predicted these three factors.

CONCLUSIONS

The results of our study may provide valuable information for education and practice in predicting nurses' intention to protect privacy of electronic medical records.

Quality clinical placements: The perspectives of undergraduate nursing students and their supervising nurses

BACKGROUND

Clinical placement for students of nursing is a central component of tertiary nursing programs but continues to be a complex and multifaceted experience for all stakeholders.

OBJECTIVES

This paper presents findings from a longitudinal 3-year study across multiple sites within the Australian context investigating the quality of clinical placements.

DESIGN

A study using cross-sectional survey.

SETTINGS

Acute care, aged care and subacute health care facilities.

PARTICIPANTS

A total of 1121 Tasmanian undergraduate nursing students and 932 supervising ward nurses.

METHODS

Survey data were collected at completion of practicum from participating undergraduate students and supervising ward nurses across the domains of "welcome and belonging," "competence and confidence: reflections on learning," and "support for learning." In addition, free text comments were sought to further inform understandings of what constitutes quality clinical placements.

RESULTS

Overwhelmingly quantitative data demonstrate high-quality clinical placements are provided. Analysis of free text responses indicates further attention to the intersect between the student and the supervising ward nurse is required, including the differing expectations that each holds for the other. While meaningful interpersonal interactions are pivotal for learning, these seemingly concentrated on the relationship between student and their supervisor-the patient/client was not seen to be present.

CONCLUSIONS

Meaningful learning occurs within an environment that facilitates mutual respect and shared expectations. The role the patient has in student learning was not made obvious in the results and therefore requires further investigation.

An exploration of Operating Department Practice students' experiences of placement support during their first perioperative clinical placement

BACKGROUND

National and International research shows student anxiety and stress levels are high during times of clinical practice, especially during initial placement allocations. Current literature stresses the importance of preparing students for clinical placements but it is not clear what information students require to adequately prepare them. This study explored Operating Department Practice students' experiences during their first placement.

METHODS

A focus group approach was used to explore the experiences of Operating Department Practice students immediately following their first clinical placements. Following pilot study work a small focus group study was conducted. Data were analysed thematically providing a large amount of in-depth rich data.

FINDINGS

Three main themes were identified; information, placement and learning experience. Students highlighted inconsistencies in their mentoring, exacerbated by inaccurate information provided by the university. Students felt confused as a result.

CONCLUSION

It was found important for students to feel welcomed and supported by the mentoring processes in order to foster a sense of belonging. Information given by the university should be accurate and effective. This can only be achieved by closer collaboration between the university and practice providers.

Factors influencing student nurse decisions to report poor practice witnessed while on placement

BACKGROUND

While it is commonly accepted that nursing care is generally of a good standard, it would be naïve to think that this is always the case. Over recent years, concern about aspects of the quality of some nursing care has grown. In tandem with this, there is recognition that nurses do not always report poor practice. As future registrants, student nurses have a role to play in changing this culture. We know, however, relatively little about the factors that influence student decisions on whether or not to report. In the absence of a more nuanced understanding of this issue, we run the risk of assuming students will speak out simply because we say they should.

OBJECTIVES

To explore influences on student decisions about whether or not to report poor clinical practice, which is a result of deliberate action and which is witnessed while on placement.

METHODS

Qualitative interviews were conducted with thirteen pre-registration nursing students from the UK. Participants included both adult and mental health nurses with an age range from 20 to 47. Data were analysed to identify key themes. Category integrity and fit with data were confirmed by a team member following initial analysis.

RESULTS

Four themes. The first of these, 'I had no choice' described the personal and ethical drivers which influenced students to report. 'Consequences for self' and 'Living with ambiguity' provide an account of why some students struggle to report, while 'Being prepared' summarised arguments both for and against reporting concerns.

CONCLUSION

While there is a drive to promote openness in health care settings and an expectation that staff will raise concerns the reality is that the decision to do this can be very difficult. This is the case for some student nurses. Our results suggest ways in which educationalists might intervene to support students who witness poor practice to report.

Facilitative and obstructive factors in the clinical learning environment: Experiences of pupil enrolled nurses

Background

The clinical learning environment is a complex social entity that influences student learning outcomes in the clinical setting. Students can experience the clinical learning environment as being both facilitative and obstructive to their learning. The clinical environment may be a source of stress, creating feelings of fear and anxiety which in turn affect the students' responses to learning. Equally, the environment can enhance learning if experienced positively.

Objectives

This study described pupil enrolled nurses' experiences of facilitative and obstructive factors in military and public health clinical learning settings.

Method

Using a qualitative, contextual, exploratory descriptive design, three focus group interviews were conducted until data saturation was reached amongst pupil enrolled nurses in a military School of Nursing.

Results

Data analysed provided evidence that acceptance by clinical staff and affordance of self-directed learning facilitated learning. Students felt safe to practise when they were supported by the clinical staff. They felt a sense of belonging when the staff showed an interest in and welcomed them. Learning was obstructed when students were met with condescending comments. Wearing of a military uniform in the public hospital and horizontal violence obstructed learning in the clinical learning environment.

Conclusion

Students cannot have effective clinical preparation if the environment is not conducive to and supportive of clinical learning, The study shows that military nursing students experience unique challenges as they are trained in two professions that are hierarchical in nature. The students experienced both facilitating and obstructing factors to their learning during their clinical practice. Clinical staff should be made aware of factors which can impact on students’ learning. Policies need to be developed for supporting students in the clinical learning environment.

'My mentor kicked a dying woman's bed…' analysing UK nursing students' 'most memorable' professionalism dilemmas

AIM

To provide depth and breadth in the analysis of nursing students' written narratives of 'most memorable' professionalism dilemmas.

BACKGROUND

While nursing students are taught professionalism through formal curricula, they commonly experience workplace-based professionalism dilemmas. Although non-UK studies have begun to explore students' lived experiences of dilemmas, they lack detail about when and where dilemmas occur, who is involved, what students do and why and how students feel.

DESIGN

Online survey of healthcare students including 294 nursing students from 15 UK nursing schools.

METHOD

Nursing students provided a written narrative of their most memorable dilemma (December 2011-March 2012) as part of a survey examining the impact of professionalism dilemmas on moral distress. We conducted thematic and discourse analysis of all narratives and narrative analysis of one exemplar.

FINDINGS

The most common themes were patient care dilemmas by healthcare personnel or students, student abuse and consent dilemmas. Of the dilemmas, 49·6% occurred over 6 months previously, 76·2% occurred in hospitals and 51·9% of perpetrators were nurses. 79·3% of students reported acting in the face of their dilemma. Of the narratives, 88·4% contained negative emotion talk and numerous significant relationships existed between types of emotion talk and dilemmas. Our narrative analysis demonstrates the impact of dilemma experiences through emotion talk and more subtle devices like metaphor.

CONCLUSION

Findings extend previous research with nursing and medical students. Nurse educators should help students construct emotionally coherent narratives to make sense of their experiences, actions and identities and to better prepare them for future professionalism dilemmas.

Learning in action: developing safety improvement capabilities through action learning

Patient safety is one of the greatest challenges facing health care today and nurses are well placed to find opportunities for enhancing care and making it safer. Nurse education has an important role to play in ensuring future professions have capabilities and confidence to meet this challenge however this requires new pedagogies in nurse education. This paper reports on an initiative to develop the safety improvement and leadership capabilities of final year nursing students using Action Learning to support students to undertake a safety improvement project in the clinical setting. A qualitative, interpretive research approach was used to explore students' experiences of participation in Action Learning. 52 nursing students from a UK University participated in the study. Student accounts of their experiences were generated through focus group and individual interviews and data were subject to thematic analysis. Findings are discussed in relation to three categories including "creating an enabling environment", "learning through action and reflection" and "the emergence of safety improvement and leadership practices." The study findings provide valuable insights into how AL processes can engender personal leadership capabilities and support students to make a valuable contribution to safer care practices, both as students and as future health care professionals.

Patient safety in nursing education: contexts, tensions and feeling safe to learn

Education is crucial to how nurses practice, talk and write about keeping patients safe. The aim of this multisite study was to explore the formal and informal ways the pre-registration medical, nursing, pharmacy and physiotherapy students learn about patient safety. This paper focuses on findings from nursing. A multi-method design underpinned by the concept of knowledge contexts and illuminative evaluation was employed. Scoping of nursing curricula from four UK university programmes was followed by in-depth case studies of two programmes. Scoping involved analysing curriculum documents and interviews with 8 programme leaders. Case-study data collection included focus groups (24 students, 12 qualified nurses, 6 service users); practice placement observation (4 episodes=19 hrs) and interviews (4 Health Service managers). Within academic contexts patient safety was not visible as a curricular theme: programme leaders struggled to define it and some felt labelling to be problematic. Litigation and the risk of losing authorisation to practise were drivers to update safety in the programmes. Students reported being taught idealised skills in university with an emphasis on 'what not to do'. In organisational contexts patient safety was conceptualised as a complicated problem, addressed via strategies, systems and procedures. A tension emerged between creating a 'no blame' culture and performance management. Few formal mechanisms appeared to exist for students to learn about organisational systems and procedures. In practice, students learnt by observing staff who acted as variable role models; challenging practice was problematic, since they needed to 'fit in' and mentors were viewed as deciding whether they passed or failed their placements. The study highlights tensions both between and across contexts, which link to formal and informal patient safety education and impact negatively on students' feelings of emotional safety in their learning.

Views and perceptions of nursing students on their clinical learning environment: teaching and learning

INTRODUCTION

The clinical learning environment constitutes an initial area of professional practice for nurses and student opinion contributes to its improvement.

PURPOSE

The assessment of students' views and perceptions of a Greek nursing school on their clinical learning environment.

MATERIAL AND METHODS

The study was concurrent and included 196 students. We used the published questionnaire "Clinical Learning Environment Inventory (CLEI)" which is a tool for identifying and assessing Nursing students' perceptions of the psychosocial characteristics of their clinical learning environment. The questionnaire was anonymous and completed by the students themselves during their clinical training at the hospital. We conducted inductive and descriptive statistics. The level of statistical significance was set at p<0.05. The statistical program SPSS 16.0 was used.

RESULTS

The highest mean score for the Actual Clinical Learning Environment was observed in the scales of "Personalization" (23.97) and "Task orientation" (23.31) while for the Preferred Clinical Learning Environment in the scales of "Personalization" (27.87), "Satisfaction" (26.82) and "Task orientation" (26.78). The lowest mean score for the Actual Clinical Learning Environment was found in the scales of "Innovation" (19.21) and "Individualization" (19.24) while for the Preferred Clinical Learning Environment in the scales of "Individualization" (22.72) and "Involvement" (24.31). Statistically significant positive correlation was found between "Satisfaction" and all other scales of the CLEI.

CONCLUSIONS

There is a noticeable gap between the expectations and reality of the clinical learning environment for the students in nursing. Reorganization of the educational framework is needed with an emphasis on innovation and individualization.

Evaluating the preceptor role for pre-registration nursing and midwifery student clinical education

AIM

The aim of this research is to evaluate the perceptions of the Registered Nurse (RN), Registered Midwife (RM) and Enrolled Nurse (EN) about their experience of preceptoring an undergraduate student within a large Local Health District in New South Wales (NSW) Australia.

BACKGROUND

In the current Health Workforce Australia (HWA) literature, the term 'Clinical Supervisor' has subsumed the role of mentor, preceptor, buddy and facilitator of clinical practice. Preceptor in this paper describes the supervisory, facilitating and teaching role of the registered nurse in the clinical practice undergraduate nursing and midwifery educational pairing.

DESIGN

A quantitative cross sectional design was used and data collected using the Clinical Preceptor Experience Evaluation Tool (CPEET), a previously validated and reliable survey tool.

METHOD

Nurses and Midwives across nine acute care facilities that preceptor undergraduate students were invited to complete the survey between March and May 2012.

RESULTS

There were 337 survey respondents across nine acute hospitals included in this study (22.5% response rate). Differences were observed between preceptors who had training in precepting in three of the subscales. Differences were observed in all four subscales between those preceptors with access to university facilitators in their location and those without immediate access.

CONCLUSION

The majority of preceptors score highly on all subscales indicating they are generally satisfied with the role of precepting. Significant differences on several items suggest that some aspects of the role are more challenging and less satisfying than others.

The South African Military Nursing College Pupil Enrolled Nurses’ experiences of the clinical learning environment

The study focused on the clinical learning experiences of Pupil Enrolled Nurses (PENs) within the military health service. The purpose of the research was to explore and describe the learning experiences of PENs within the Military health clinical learning environment. An explorative, descriptive, contextual design which is qualitative in nature was used to guide the study. The military as a training institution prides itself on preparing nurses both as soldiers and nurses, this could be both challenging and exasperating for students, as the scopes are diverse. Being notably very hierarchical, the military’s rules constantly take precedence over nursing rules. For the duration of nursing training, students are allocated in the clinical learning area to acquire competencies such as problem solving, cognitive and psychomotor skills (Kuiper & Pesut 2003:383). Students learn how to merge theory and practice and apply theories in the practical sense. This is however, not done in isolation from the military codes, as they are intertwined. Attendance of military parades and drills are incorporated during this phase. This could create missed opportunities from the clinical learning as students are expected to leave the clinical setting for this purpose. Three focus group sessions were conducted and the experiences of the students, as narrated by themselves, yielded valuable insights. The researcher wrote field notes and assisted with the management of the audio tapes for easy retrieval of information. Data was analysed by the researcher, independent of the cocoder. Two themes relating to the PENs’ learning experiences emerged from the data analysed: (1) facilitators of clinical learning, (2) and barriers to clinical learning. The findings obtained depicted those factors which facilitated and obstructed student learning. These findings made it possible for the researcher to make recommendations concerning positive interventions which could be taken to enhance learning.Die studie het gefokus op die kliniese leerervarings van leerling-ingeskrewe verpleegkundiges (LIV’s) in die militêre gesondheidsdiens. Die doel met die navorsing is om die kliniese leerervarings van LIV’s binne die militêre gesondheidsomgewing te verken en te beskryf. ’n Verkennende, beskrywende, kontekstuele ontwerp, kwalitatief van aard, is gebruik om die studie te rig. As ’n opleidingsinstituut roem die weermag hulle op die opleiding van verpleegkundiges as soldate, en nie slegs verpleegkundiges nie. Dit kan uitdagend sowel as frustrerend vir studente wees omdat die omvang van hierdie opleiding so divers is. In die weermag, bekend vir sy hiërargie, geniet militêre reëls gedurig voorrang bo verpleegkundige reëls. Vir die duur van die verpleegopleiding word studente aan die kliniese leerareas toegewys om vaardighede soos probleemoplossing en kognitiewe en psigomotoriese vaardighede te bekom (Kuiper & Pesut 2003:383). Studente leer hoe om teorie en praktyk te verenig en teorie in die praktyk toe te pas. Dit word egter nie geïsoleerd van militêre kodes gedoen nie, aangesien dit alles vervleg is. Bywoning van militêre parades en drilsessies moet in hierdie fase geïnkorporeer word. Dit kan tot verbeurde kliniese opleidingsgeleenthede lei, aangesien daar van studente verwag word om die kliniese omgewing vir hierdie doeleindes te verlaat. Drie fokusgroepsessies is gehou en die ervarings van die studente, soos deur hulleself vertel, het waardevolle insigte gelewer. Die navorser het veldnotas gemaak en was behulpsaam met die hantering van bandopnames om die herroeping van inligting te vergemaklik. Die navorser het die data onafhanklik van die medekodeerder geanaliseer. Twee temas met betrekking tot die leerervarings van LIV’s het na afloop van die data-analise aan die lig gekom: (1) fasiliterende faktore vir kliniese leerervaring, (2) struikelblokke tot kliniese leerervaring. Die bevindinge dui op faktore wat die studente se leerervaring fasiliteer, asook struikelblokke tot leerervaring. Na aanleiding van hierdie bevindinge het dit moontlik gemaak vir die navorser om aanbevelings te maak aangaande positiewe intervensies wat toegepas kan word ter bevordering van die leerervaring.

Development and psychometric testing of the Ascent to Competence Scale

AIM

This paper reports the development and psychometric testing of the Ascent to Competence Scale, an instrument designed to measure nursing students' perceptions of the quality of their clinical placement experience.

BACKGROUND

The key purpose of clinical placements is to facilitate students' learning and progress toward the attainment of competence. The attainment of competence requires personal commitment and active involvement of students; support and guidance of clinical and academic staff; and clinical environments that are welcoming and inclusive of students.

METHOD

The items for the Ascent to Competence Scale were identified following a critical review of the literature. Content and face validity were established by an expert panel. During 2010 the instrument was tested with third year nursing students (n=88) from one Australian university. Exploratory factor analysis with promax oblique rotation was used to determine construct validity and Cronbach's coefficient alpha determined the scale's internal consistency reliability.

RESULTS

The final scale demonstrated satisfactory internal consistency (alpha 0.98). Exploratory factor analysis yielded a three-component structure termed "Being welcomed"; "Belongingness" and "Learning and competence". Each subscale demonstrated high internal consistency: 0.89; 0.96; and 0.95 respectively.

CONCLUSION

The Ascent to Competence Scale provides a fresh perspective on clinical placements as it allows for the relationship between belongingness, learning and competence to be explored. The scale was reliable and valid for this cohort. Further research in different contexts would be valuable in extending upon this work.

RELEVANCE TO CLINICAL PRACTICE

The Ascent to Competence Scale profiled in this paper will be of benefit to both educational and healthcare institutions. The use of a quantified yardstick, such as the Ascent to Competence Scale, is important in evaluating the efficacy of programs, placements and partnerships between higher education and health services.

Ethical concerns in the student/preceptor relationship: a need for change

Nursing schools are required to ensure that the clinical and academic milieu prepares nurses not only to recognize but also to act on various ethical issues. As a result of our years teaching nursing ethics to undergraduate nursing students we have come to believe there is a disconnect between classroom teaching and students' experiences in practice. How then can nurse educators help nursing students not only to see the ethical components of their work but also to take the necessary steps to solve ethical dilemmas and challenge unethical practice? One such strategy is the use of preceptorship. In this paper, we set out to learn about nursing students' ethical encounters in the clinical area, specifically those within the preceptor/student relationship. To this end we conducted an integrative review and are weaving in Gesler's (1992) concepts who argued that ethical issues play out in our physical and social environments. We identified nine articles that describe students' perceptions of ethical problems in their relationships with preceptors. However, it was rare for the authors of these articles to label these as 'ethical' issues. The integrative review revealed first, that students describe ethical issues in their narratives, and second, their most common response to these issues is silence. We continue to be concerned that nursing students' classroom learning of ethics is disconnected from their everyday nursing practice. Further research and education implications are discussed and explored in this paper.

Recovery as a threshold concept in mental health nurse education

This theoretical review discusses the complexities of understanding and applying the concept of recovery for pre-registration mental health nursing. It is suggested that reframing recovering as a threshold concept in mental health nurse education will illuminate the issues and challenges that students and educators appear to encounter. This is attributed to the transformative nature of learning in this area which requires the student to reassess beliefs and prejudices and enter into an uncertain territory where knowledge and values are questioned. Educational approaches are proposed which aim to facilitate the depth of learning required to engage with the concept of recovery at this level whilst responding sensitively to the students' potential reluctance, discomfort and in some cases resistance. Teaching recovery in mental health nursing therefore challenges educators to use any and every approach that stimulates emotional and transformational learning. As such, recovery in mental health is a threshold concept, that once learned, may transform not only the learner in the classroom but their practice in the future.

Nursing students' perceptions of learning in practice environments: a review

Effective clinical learning requires integration of nursing students into ward activities, staff engagement to address individual student learning needs, and innovative teaching approaches. Assessing characteristics of practice environments can provide useful insights for development. This study identified predominant features of clinical learning environments from nursing students' perspectives across studies using the same measure in different countries over the last decade. Six studies, from three different countries, using the Clinical Leaning Environment Inventory (CLEI) were reviewed. Studies explored consistent trends about learning environment. Students rated sense of task accomplishment high. Affiliation also rated highly though was influenced by models of care. Feedback measuring whether students' individual needs and views were accommodated consistently rated lower. Across different countries students report similar perceptions about learning environments. Clinical learning environments are most effective in promoting safe practice and are inclusive of student learners, but not readily open to innovation and challenges to routine practices.

A modest start, but a steady rise in research use: a longitudinal study of nurses during the first five years in professional life

Background

Newly graduated nurses are faced with a challenging work environment that may impede their ability to provide evidence-based practice. However, little is known about the trajectory of registered nurses' use of research during the first years of professional life. Thus, the aim of the current study was to prospectively examine the extent of nurses' use of research during the first five years after undergraduate education and specifically assess changes over time.

Method

Survey data from a prospective cohort of 1,501 Swedish newly graduated nurses within the national LANE study (Longitudinal Analyses of Nursing Education and Entry in Worklife) were used to investigate perceived use of research over the first five years as a nurse. The dependent variables consisted of three single items assessing instrumental, conceptual, and persuasive research use, where the nurses rated their use on a five-point scale, from 'never' (1) to 'on almost every shift' (5). These data were collected annually and analyzed both descriptively and by longitudinal growth curve analysis.

Results

Instrumental use of research was most frequently reported, closely followed by conceptual use, with persuasive use occurring to a considerably lower extent. The development over time showed a substantial general upward trend, which was most apparent for conceptual use, increasing from a mean of 2.6 at year one to 3.6 at year five (unstandardized slope +0.25). However, the descriptive findings indicated that the increase started only after the second year. Instrumental use had a year one mean of 2.8 and a year five mean of 3.5 (unstandardized slope +0.19), and persuasive use showed a year one mean of 1.7 and a year five mean of 2.0 (unstandardized slope +0.09).

Conclusion

There was a clear trend of increasing research use by nurses during their first five years of practice. The level of the initial ratings also indicated the level of research use in subsequent years. However, it took more than two years of professional development before this increase 'kicked in.' These findings support previous research claiming that newly graduated nurses go through a 'transition shock,' reducing their ability to use research findings in clinical work.

Nursing students and the issue of voice: a qualitative study

AIMS AND OBJECTIVES

This paper reports the findings of part of a larger study that explored the empowerment of nursing students in clinical practice. The focus here is on the phenomenon of 'voice' and the extent to which nursing students are able to exercise voice during their clinical practice experiences.

BACKGROUND

There is evidence to suggest that nursing students are 'silenced' in clinical practice and that they are unable to make their voices heard, even when they witness poor nursing practice.

METHODS

This study explored the experiences of thirteen nursing students in the UK as they progressed through their undergraduate nursing programme. The study was underpinned by hermeneutic phenomenology. Data were generated through annual, semi-structured interviews and focus group discussions.

FINDINGS

In situations that called for nursing students to 'speak up' they did one of two things: exit or voice. However, there was bridging of these actions in the form of 'negotiating voice'.

DISCUSSION

Theoretically, findings of this study can be understood in relation to Hirschman's notions of 'exit and voice'. However, rather than being dichotomised extremes, an exit-voice continuum is proposed.

CONCLUSIONS

Students are often silenced in clinical practice, but to overcome this they negotiate situations in an attempt to be heard. This paper provides new insight into the means by which nursing students can be supported to avoid the exit option, in favour of exercising voice.

Fitness for practice in nursing and midwifery education in Scotland, United Kingdom

AIM

The aim of this paper is to report findings from a major study that evaluated the Fitness for Practice nursing and midwifery curriculum in Scotland, UK.

BACKGROUND

The competence of student nurses and midwives at the point of registration has been the focus of debate and research. However, no major study, on such a large scale, had specifically evaluated pre-registration programmes to determine whether they enabled students to achieve 'fitness to practice'.

DESIGN

The study had a broad evaluation design conducted in three phases using a mixed methodology.

METHOD

Phase 1 involved questionnaires, Objective Structured Clinical Examination's (OSCE) and curriculum evaluation. Phase 2 involved semi-structured interviews (some telephone) and focus groups across main stakeholders: students (n = 78), mentors (n = 78), practice-education facilitators (n = 24), academics (n = 59), senior clinical (n = 46) and education managers (n = 16), service users and carers (n = 10).

RESULTS

The findings suggest that the Fitness for Practice curriculum model in Scotland has on the whole been successful. The key finding is the predominant opinion of stakeholders that newly qualified nurses and midwives are perceived as being fit for practice at the point of registration. A perceived lack of confidence is, as with all transitions to new roles, an understandable outcome.

CONCLUSIONS

Previous concern that student nurses and midwives are not 'fit for practice' has focused on the perceived lack of clinical skills at the point of registration, not on competence to practice in general. This study demonstrates that this is an important distinction and recognises that registration is only the beginning of a life long learning experience.

RELEVANCE TO CLINICAL PRACTICE

Students need to be supported to develop their confidence following registration as well as additional skills in their chosen field of practice. Appropriate mentorship and a period of preceptorship should be in place to accommodate this.