Student Essay 2003 - The Learning Experience of a student nurse, a critical analysis.
My learning throughout the first year has been helped by an unerring optimism in the value of nursing, and an appreciation that each and every daily interaction augments my experience (Spouse 2003:200, Marris 1986 cited by Johns 2000:65). This enthusiasm, however, has caused an inhibitory effect on my self-directed researching, and created conflict in some placement areas. Whilst developing my role as a nurse, my activities as a person at home and beyond have diminished, as I attempt to adjust to the demands of both domains (Spouse 2003:109). I resent distracting influences, and frequently domestic pressures restrain my desired pace to accumulate factual knowledge. As described by Palmer et al. (1994:40), my learning can oscillate between two extremes, “all or nothing”. Spouse (2003:42) depicts the student nurses’ need to develop multi-tasking skills emotionally, mentally and physically as they are caught between the cultures of clinical areas, peer driven University life and home. The conflicts arising from these settings creates a disharmony, which I believe for some, may undermine nursing as a career choice. The developmental educative process in nursing is a sophisticated and complex combination of scientific, logical, humanitarian, communicative experiences and psychomotor skills, designed to consolidate abilities and produce “knowledgeable doers” (Sajiwandani 2000:51, Slevin 1992:36, Cheung 1992:159). Level one students are progressively introduced to models of self-assessment, for example Johns’ Model of Structured Reflection (1993:11), patient assessment models, for example Roper et al. Activities of Living (1999). They are also exposed to many intellectual academic and practical concepts simultaneously within the multi-various placements. The learning experience is an attempt to focus the mind, and is defined by Kolb (1986, cited by Earnshaw and Dale 1994:16), as part of the perpetual cycle of reflection, generalisation and application of any event. This process is a vital and fundamental principle in the creation of a sound, and intellectually processed evidence-base of knowledge required by Nursing and Midwifery Council (NMC) (2002 6:8) to underpin professional nursing practice. Eligibility to practice requires completion of the nursing curriculum and qualification, and registration with the NMC. Throughout training, student nurses are obliged to meet educational standards, demonstrating they are: ‘competent, health-orientated, thinking, reflective, change-receptive and accountable practitioners’ (Slevin 1992:31). Proof of competence comes from a documented evidence-base, tutors, mentors, assignment and examination results, and is based on continuum of regular assessments. It is ultimately mentors in clinical practice and tutors in academic practice who determine level of attainment and discriminate between satisfactory and unsatisfactory student performance (Walton and Reeves 1999:44).
The good and the not always so good: the experience in clinical placement – working alongside the mentor
MacLeod (1994:46-48) develops the argument that there is real value in the everyday ward experience. There is a complex interface between the lecture-based, group learning, intertwining with the noticing, understanding, responding in practice-based experiences. Here, the students take the initiative to interpret, participate and immerse themselves with practical care issues under the guidance of an assessing mentor. The NMC (2002: 6.4:8) states that as a registered practitioner, a nurse has a duty to facilitate students of nursing, to develop their competence, that is, they have a responsibility to assist in their training. This however, makes an assumption based on point 6.1, that the mentor has, to the best of their abilities, kept-up in learning skills and competencies required to develop their own performance. In all forms of mentored “supervision”, the personalities and experiences of each staff member and student will provide for different qualities of transfer of learning (Hilgard et al. 1971, cited by Sajiwandani 2000:69). That is, for a student to recognise the relevance of a situation, requires they have a prior knowledge or familiarity with that experience (Spouse 2003:200). Initially, the mentor will be obliged to direct the student’s attention to relevant experiences and initiate the reflective process. Therefore, one of the major influences of a student’s learning experience is the quality and nature of mentorship (Spouse 2003:214). Where mentors befriend students and provide good support, they legitimise student’s work, who in turn readily seek opportunities to participate to achieve learning outcomes. Where this relationship is lacking, students are unable to gain access to professional practical knowledge (Spouse 2003:210). In this respect, where worst case situations manifest and structured assistance is missing, the most helpful card in a student nurse’s hand, is their supernumerary status. It is the student’s responsibility to foster better relations or to be reassigned to a different member of staff, explore relationships with patients, colleagues as well as literature, thereby stimulating their understanding. Communication with fellow students at this time, may also improve their commitment to study and reduces a potential sense of isolation created by the lack of attention from qualified staff (Spouse 2003:211). Through this reflective discussion it is commonly noticeable that some mentors either misunderstood their role or were too preoccupied by their own responsibilities to engage with the students on their anticipated agenda. The reflective process on the other hand also enables the student to gain a sense of proportion. Whilst researched academic study underpins practice, there are frequently qualifications made by nursing staff about ward performed procedures, stating that ‘real-life’ situations employ differing methods to those taught in the class-room. These instances challenge student’s assumptions and provide the impetus for further clinical reflective investigation (Spouse 2003:205). They also serve to demonstrate the existence of multiple methods of care delivery, attuning them to motives and perspectives of other practitioners in the health care team, indicating that other’s, have legitimate reasoning (Palmer et al. 1994:69). The traditional apprenticeship model does not fit well in today’s nurse training. Instead, mentoring uses a form of ‘scaffolding’ practice, whereby students work alongside, are provoked to think aloud, and, where they not likely to become overwhelmed, stretched in their abilities to undertake tasks in a safe environment. (Glen and Leiba 2002:120). The mentor, monitoring a student’s readiness to learn and capacity to perform, is guided by this framework. Students are not encouraged to be ‘task-orientated’ automatons (Slevin 1992:116, Hunt 1992:101). The taught nursing process ‘puts the patients first’, centrally and viewed holistically (Roper et al. 1999:13), that is appreciating that the patient exists as a member of a social culture, who has (amongst others), a role, status, relationships and spiritual needs (Roper et al. 1999:27). In many instances, however, students will meet mentors who have ‘burnt-out’, as a result of lack of satisfactory working environments, long hours, diminished professional respect, and inability to cope with levels of anxiety in a constructive manner. The burnt-out qualified staff may have experienced, over prolonged periods, reinforced subordination from other members of the health-care team, effectively disempowering them. Consequently, through a lack of ability to articulate, the professionals attitude alters in negative ways. These negative responses manifest themselves in the mentor’s loss of concern and tendancy to resort to task-allocation or respond in detatched and mechanical fashion (Glen and Leiba 2002:133, Johns 2000:197). When students are faced with such situations in clinical settings, it is very easy to adopt a similar approach. The student should attempt to engage staff in reflective discussion, as a means to remind them of their own reflection, whilst acknowledging their situation, because as mentioned by Moll (1990) cited by Spouse (2003:199), there is an inextricable link between practice and theory. Their influence on each other is mutual, and without good practice, theory has no meaning. Theoretical understanding therefore is difficult to explore when faced with poor practice. The benefits to the student of the continuously asessed nature of their competence, monitored throughout the nursing curriculum, is that it is not superficial. It is not dependent on the mood of the mentor in a busy clinical environment, or the particular relationship between a student and a lecturer (Walton and Reeves 1999:80). It is an up-dated measurement of progress and achievement. It encompasses real world situations, adult-orientated problem-solving, close, (but unthreatening), supervision and is graded to the student’s expected ability (Walton and Reeves 1999:83). Snapshots of, and overall performance gradings, interpreted reflectively, will begin to acclimitise students to the reality of critical ambience they can expect to find working on a ward. Students of nursing show a great flexibility of thought, but they are not always able to articulate their anxieties, either about study or clinical placements (Palmer et al. 1994:77). Reassurance about their work from mentors and tutors, may serve to reinforce, an otherwise dwindling, confidence and self-awareness. The evidence-base requiring development by all student nurses differs for each individual (Ewles and Simnett 1999:121). It is driven by experience and a need to achieve specified learning outcomes in clinical placement. Without reflection, and the tutor’s corroboration, students may remain unfocused and disillusioned by the lack of strict guidelines to assist in creating this document. Consistent nurturing by tutors helps to convey the complexity of the concept of underpinning knowledge. Nursing cannot happen in social isolation and students require comprehensive acknowledgement to prevent both physical and mental exhaustion (Palmer et al. 1994:90). Support and guided reflection provided by mentors during placement and by tutors, preceeding, during and following placements, serve to reaffirm the validity of the student’s work, and to justify that they are not being used as another pair of hands. These vital discussionary times allow the past experiences of the student to be positively, selectively filtered and thus help in generating new strategies. As Dewey (1933 cited by Palmer et al.1994:89), expressed, the notion of reflective learning is primarily a willingness to learn, but further to this is a responsibility to search for meaning within situations.
A qualified nursing practitioner is a professionally trained integrated member of the health-care team. This professional education should be life-long, beginning with three years pre-registration factual knowledge and skill acquisition. As previously described there is a symbiotic relationship between nursing’s craft and nursing wisdom, and they are required in practice simultaneously. Despite the apparent impression given by traditional methods of education that these categories exist seperately, for nursing they are fluidly cohesive, one informing the other, through reflective analysis (Watts 1992:171). The elements experienced by nursing students during their training are bonded internally together to authenticate their practice, by unleashing possibilities inherent in the situation between patient and the therapeutic self (Kirby and Slevin 1992:70). The following guidelines are intended to promote improvements in the student’s learning experience. Qualified staff who direct pace and direction of study need to encourage students in imaginative and innovative ways to prepare them for adoption of new concepts and the flood of changes and that they will need to make in all aspects of their life. Support such as this will guide them through the vulnerable initial stages of their steep learning curve of level one, as echoed by the dissonance described in the first paragraph of the essay.
I would like to see better preparation of mentors by lecturer-practitioners within clinical placements, in order to foster environments of positive, constructively planned activities. From this, students can gain insight to challenge their assumptions and lay-view of nursing. In this respect, I would like those in the clinical settings to be encouraging students rather than attempting to degrade their efforts by dismissing their academic research based interest in the subject of nursing. I would like access to professional teaching staff in-college at all times, especially immediately prior to and post placement. I hope for tutor liaison with mentors more regularly within the clinical settings, serving to remind mentoring nurses that their duty to support students is real, and linked with Higher Education Establishments. I would like to see in-college tutors giving better, basic and consistent guidance whilst initially developing the concepts of critical reflective consciousness and the production of an evidence-base of knowledge thus strengthening the intellectual and practical growth of students.