Another way to help students develop self-learning techniques is facilitating their learning of how to integrate their knowledge. In Canada, Hicks-Moore (2005) reported that, although it took time to assist baccalaureate nursing students in understanding and development of useful concept maps in the early stage of their clinical training, applying this strategy could facilitate their effective data gathering and critical thinking. It is a strategy that encourages students‘ application and synthesis. The maps enabled them to see clear connections for patients‘ problems and how one concern could affect another. Employing this strategy led the students to a deeper understanding about how diagnostic information, medications, and signs and symptoms of their patients were related. They could understand why they had to do the care they were doing for their patients. The concept map strategy challenged the students to identify and question data to support their hypotheses, as well as allowing nursing instructors to assist them by asking questions, sharing expertise and providing additional information they might not have realised was important. This could make the students search for ways to assimilate new knowledge with their existing understanding and to integrate what they had learned in theoretical sessions to address their clients‘ problems.
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In trying to improve students‘ ability to integrate their learning and the clinical learning environment in Sweden, Ehrenberg and Häggblom (2007) applied Problem Based Learning (PBL) and implemented a new model for supervision during 11 weeks of acute care clinical training for second year nursing students. On evaluating the experience of the 45 students and 30 preceptors, the findings showed both groups considered the supervised reflections very positive. The students stated that their opportunities to gain an overall picture of patient care were enhanced. They also appreciated being respected and trusted for their responsibilities in the care activities, which increased their self-esteem and self-confidence. The findings of this study indicate the value of PBL and reflection strategies for enhancing nursing students‘ learning, preparing them for their working life, as well as improving the clinical learning environment.
In another study testing a strategy for integrating learning, Nielsen (2009) applied a concept-based learning method, using the clinical judgment model as a foundation for pediatric clinical learning in third year American baccalaureate nursing students. Concept-based learning activities had been designed to guide students‘ study of specific concepts that were viewed as essential for children and family care. The activities based on this model required students to gather information about specific clinical problems, interpret findings, deliver relevant nursing care, and then reflect on the experience, both individually and as a group to consider how the concept presented in different patients. She found that the method added significantly to students‘ clinical learning as it could encourage deep understanding in clinical phenomena for them. The findings of this study echo the learning process of nursing students in new clinical situations by integrating theoretical knowledge and their critical thinking. The method could facilitate the development of students‘ nursing skills by connecting concepts to other new patient care situations that they might face in the future. It can promote nursing student progression to higher levels of thinking, which can drive them to move on a continuum from novice to professional.
Using an ethnographic approach, another Swedish study aimed to describe strategies and techniques that 16 preceptors applied in the training of Swedish undergraduate nursing students. Carlon, Wann-Hansson, and Pilhammar (2009) found several different methods that supported integration. The observational field notes and focus group
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interviews illustrated preceptor teaching as an actual continuing process: adjusting the level of precepting, performing precepting strategies, and evaluating precepting. Preceptors started with trying to get to know the students to get a picture of how and what they had to learn and then planned to meet the learning objectives that emerged. In this step, based on their preconceived ideas and previous experience, however, preceptors had preconceived expectations as to what students should know and be able to do in their particular year of study. When coming to the step of performing supervision, preceptors stated that first it was essential that they made a trusting relationship with students, so students felt safe to make decisions and know when and to what extent they should ask for help. They thought that this was a fundamental factor for quality precepting. They then were aware of encouraging a free thinking climate for students. In order to understand, preceptors believed that students should be able to ask anything they want to know. This approving climate was very important. For them, there were no stupid questions. If the answers they gave students were different then that was seen as a starting point for discussion.
Moreover, the same study revealed that preceptors wanted to be close to students, but not to hover over them. They had to create safe learning environment for their students. To train nursing students, they thought they had to apply several techniques such as demonstration in combination with students‘ observation before encouraging them to try, especially for teaching psychomotor skills. For cognitive training, these preceptors revealed their effort to use different techniques to promote reflection, critical thinking, and problem solving skills of their students. For example, low-level or factual questioning for knowledge recall, giving cues for being extra attentive before probing with reflective questions, and encouraging students to verbalise their thinking; they found were effective for clinical teaching. Furthermore, giving situational feedback to create a feeling of security for students, and sometimes reinforcing was needed to confirm what students were performing were also main methods they used. The preceptors took a moment each day to reflect on their students‘ nursing actions. When passing the half time point, the evaluation about what students had achieved and what they still had to learn was done to guide the remaining part of their clinical practice. The final assessment was also usually held in the form of a conclusion and recommendations. Both the students and preceptors benefited from knowing what they needed to focus on during their coming clinical practice or preceptorship.
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Beyond the strategies mentioned, to facilitate nursing students to effectively develop their nursing skills, many international nursing instructors also introduce clinical simulation into nursing programmes.