Clinical internship: Developing clinical competence

In order to qualify to practise as an APN in Singapore all candidates for certification and licensure were required to complete a clinical internship. The purpose of the internship was

to develop and refine clinical competencies of the programme graduate in a designated clinical specialty. The essential structure was initially envisaged as a 12-month minimum period. In practice the length of time in the internship was often extended and at times commencement of the internship delayed. The internship was conducted under the supervision of a physician preceptor who facilitated and supervised the experience. The internship/preceptor structure was under the domain of the employer thus infrastructure and preparation for the intern period varied from institution to institution. This section consists of three subsections. It begins with descriptions of intern experiences. It is followed by

descriptions of challenges of the internship period. The final subsection examines the significance of the clinical preceptor including preceptor attributes that contribute to a positive or negative internship experience.

7.4.1 Intern experiences and challenges

The intent of the clinical internship was to refine and solidify the clinical competencies of future APNs. All APN participants indicated they knew they were required to progress to an internship period following graduation of the APN programme but at the time of the conduct of the study the internship was not well defined. Findings indicated that when the new graduate began the internship experience in a clinical setting they were often not well received. Personnel in clinical settings were unclear about the role and what to expect of the APN Intern. An exception to the struggles with execution of the internship was with the critical care specialty stream. The curriculum design included competency assessment guidelines that linked the education programme at the university to the clinical internship. Knowledge and skills gained through this approach were seen to have led to more true experiences in preparation for the internship and subsequently the APN role. However, at the time of completion of data collection this strategy had not yet been developed for other specialty streams. There was an expectation by programme graduates that they would solidify clinical competencies during the internship period. Findings revealed anxiety on the part of all APNs during their internship but they were afraid to speak up about their concerns. It was unclear who they should report to, nursing or medicine, thus contributing to tension among healthcare professionals and interns. Some interns lacked confidence in clinical decision- making and found adjustment to the role as an APN intern difficult. The experienced intern gained confidence in the role and reported more positive adjustment towards the end of the intern experience. Most APN participants reported a somewhat turbulent experience in the internship to the point where individuals in the early cohorts either did not complete the

internship or had excessive delays in completing this experience. Assistant Directors of Nursing were most often responsible for the interns but had countless responsibilities and admitted to not keeping their ‘eye on the ball’ in supervising intern experiences from the perspective of nursing. In some cases Assistant Directors of Nursing were expecting the APN interns themselves to carve out the role but interns were not in a position to do this. At the completion of data collection in 2011 this situation was improving in some institutions with better management support for APN Interns and establishment of earlier links to physician preceptors. The internship period was envisaged to provide clinical experiences leading toward clinical competence to prepare interns for the certification process and licensure. In some

instances APNs noticed retrospectively that they had not had good supervision by their supervisors and the clinical experience was not what they imagined thus they either struggled with the certification process or did not pass the oral panel interview leading to licensure. In addition, findings indicated that lack of hands on clinical experiences in the academic programme contributed to inadequate preparation for the internship and added pressure to the expectations the interns thought they should have had. One academic described experiences of students when they proceeded to the internship:

‘The student fresh from graduation then goes on to clinical [experience] as an APN Intern and is confused because they do not want to offend anyone during their internship. They would not want to offend the fellow nurses by acting as if they know more than them. They would not want to offend the doctors by actually taking on roles that they know the Medical Officers could actually do. It is not really the roles but the student’s perception of what their real roles are … there is a lot of confusion amongst people as to what extent they [interns] can actually do the APN role’ [Participant 6NEd]

Issues of role ambiguity and uncertainty as to the position of the APN in the workplace continued throughout the internship period. A more in-depth discussion regarding lack of role clarity can be found in Chapter 8: Implementation. The structure for the internship fell under the domain of each employing institution with an expectation that management would negotiate the intern experience on behalf of the APN intern; however, findings indicated that it was not clear that anyone assumed overall responsibility and accountability for the interns and their experiences thus dimensions and construct of the internship varied extensively among institutions. Ambiguity of the APN role pervaded this period of role preparation with no formal preparation initially of the interns or

preceptors for this experience. There were emerging concerns by the Ministry of Health and the Chief Nursing Officer regarding delays in completion of the internship thus the Chief Nursing Officer exerted pressure on institutions to overcome these delays. A Head of Department for nursing illustrated the situation with this quote:

‘The Chief Nursing Officer is working closely with the Directors of Nursing to transport the students in their internship and ensure that they complete the requirements of the internship in a timely way. That includes a closer connection with potential preceptors but there is no monitoring of that. There is no single point of accountability in terms of the quality of the student’s internship; the preparation and support they receive from the consultant’ [Participant 13NEd].

The Head of Department of Nursing suggested two pathways to attempt to enhance the internship:

 Development of specific connection between the clinical setting the university programme;

 Establishment of a steering committee by the Chief Nursing Officer as a

representative of the Ministry of Health to standarise the internship throughout the country.

At the time of completion of data collection in 2011 a closer liaison from the Chief Nursing Officer with the Directors of Nursing and Assistant Directors of Nursing was being

established to begin to consider these suggestions and address the internship concerns. In addition, in the face of emerging difficulties some institutions were developing strategies to enhance the intern experiences once they identified that a good intern/preceptor match appeared to be critical to a positive intern experience. The next subsection identifies factors and preceptor attributes that impacted intern experiences.

7.4.2 The preceptor: the significance to the clinical internship

The preceptor or clinical tutor was identified as a physician with expertise in an area of clinical specialty similar to the chosen specialty of the APN Intern. Preceptors were intended to guide the programme graduate as they developed clinical competence. At the time of completion of data collection APNs had not been identified as preceptors but discussion was in place to include them in the future after they had gained experience in the role. Intern clinical experiences were dependent on the physician preceptor. However, findings indicated that in the initial stages of implementation physicians agreed to become

preceptors but were uncertain of the APN role and their role as preceptors. There was considerable variability in how the physician preceptor interpreted the role and therefore variability in clinical opportunities provided for the interns. Appraisal of the intern was comprised of two parts:

 An ongoing informal preceptor evaluation of the intern during the internship period to assess if the individual was performing to the expected level of competency;

 Development and formal presentation of two clinical cases to a three person panel usually consisting of physicians who examined the intern orally after receiving and reviewing written case studies.

The employing institution, in consultation with the APN candidate, selected the physician preceptors to fill this role. Initially there were no defined criteria for a preceptor. With the introduction of the critical care stream preceptor guidelines were developed and meetings occurred among representatives of the academic programme and one employing institution. At the completion of data collection this process had not extended to other specialty

streams. Findings revealed that certain preceptor traits contributed to beneficial intern/preceptor experiences. These qualities included:

 A positive attitude to the APN role;  Availability for consultation;

 Encouragement of critical thinking and clinical decision making;  Previous experience working with APNs;

 Intrapersonal relationship with the intern of trying to ‘get going together’ and a willingness to be part of the process;

 Intern confidence in the clinical skills of preceptor.

One APN participant commented on positive experiences with a preceptor in the following quote:

‘My preceptor was very supportive. He is the one who said he knows me better than the interviewer (for certification) and feels that he should know better whether I can perform this role rather than the exit interviewer’ [APN3]

Most APN participants who experienced positive preceptor experiences concurred with this perspective and indicated that the certification process was not objective because

their preceptor would have. Preceptor characteristics reported by APNs to hinder the internship experience included:

 Preceptors who provided limited clinical opportunities for the intern;  Lack of understanding of the intern/APN role;

 Interpersonal relations between the preceptor and intern that did not facilitate learning experiences.

Most APN participants indicated that a good quality preceptor/intern dyad was pivotal to a successful internship experience. Some employers were beginning to select potential APN candidates earlier in order to prepare them better for the academic programme and

internship. In this way candidates were able to connect in advance with a preceptor and develop a rapport prior to beginning the internship. Findings indicated that less successful intern/preceptor relationships were a deterrent for completion of the certification process and exit interview. Clinical internships are a requirement for certification and licensure in Singapore. The next section examines the requirements and qualifying processes to become a licensed APN in Singapore.