Providing a Caring Clinical Learning Environment

Clinical placements enable student nurses to learn from clinical encounters with patients, clients, families and communities, and to meaningfully transfer learning from theory to practice. This integration enables student nurses to practice the art and science of nursing, and to stimulate higher orders of thinking. Furthermore, clinical placement fosters a sense of caring for others and creates opportunities for the student nurse to explore nursing values and ethics (Brown, Stevens & Kermode, 2012:609; Bruce, Klopper & Mellish, 2011:253; Gaster, 2011:20; Hutchinson & Goodin, 2013:19).

Student nurses consider clinical practice placement as a vital component of their learning process as it plays an important role in enriching their clinical competencies of the students. For student nurses to learn, they need to be accepted and valued when allocated to the clinical setting. Clinical staff should endeavour to create a positive and supportive climate that will enhance learning. Caring relationships promote trust and a sense of warmth, making student nurses feel comfortable in the clinical learning environment. They want to be invited into the social group and feel part of the team (Caka & Lekalakala-Mokgele, 2013:8; Sandvik, Eriksson & Hilli, 2014:289-290; Tiwaken, Caranto & David, 2015:69). Despite this, student nurses encounter a level of organisational or professional hierarchy in the clinical learning environment that de-personalises them and they request more time, competence, and supportive relationships with supervisors to support them in the process of learning what nursing is about, and how they can best nurse their patients. They seek an identity as nurses through community of practice and clinical work, to create their individual identity through experience, skills development, dialogue, and reflection. In addition, they want to become ward members and learn practical work under supervision (Crombie, Brindley, Harris, Marks- Maran & Thompson, 2013:1284; Hovland, 2011:38). However, teaching of skills and practices are still dominant learning during practice placement. Student nurses are not actively engaged to question the effectiveness of existing practices, and they perceive that learning environments are not conducive to initiating innovation. Yet, the mutual benefits of clinical

placement are evident. Practice nurses consider supervising student nurses as beneficial for their own personal development and also for their development in the practice nurse role (Halcomb, Peters & McInnes, 2012:727; Henderson, Cooke, Creedy & Walker, 2012:299)

A respectful, accepting attitude helps student nurses to feel more centrally located in the clinical learning environment and alleviates anxiety. A main objective of decreasing anxiety in student nurses in the clinical setting is to increase their learning and promote their continuance in nursing education (Melincavage, 2011:788). They are very sensitive during clinical education. They want to be seen and cared for, and they want their presence in clinical education to be clear; i.e. to learn and not be exploited for other tasks. Student nurses consider the purpose of clinical education to be that they should be able to apply what is learned in the classroom to patient care through teamwork and enquiry. They expect clinical education to be planned and implemented with a focus on their learning and expected learning objectives. Yet many learning opportunities are forfeited when the wards are busy, as the priority is to complete tasks rather than meet student nurses’ learning needs. In such circumstances, practice nurses prefer to perform certain procedures themselves or take over procedures commenced by student nurses to save time. Alternatively, student nurses may learn to practise “short-cut” methods in order to complete their tasks promptly. Tensions such as a lack of diverse learning opportunities, lack of equipment, difficulty in finding help when needed, theory-practice gap conflicts and competition with other student nurses to perform skills are problems reported by them during clinical placement. More attention could be paid to recognising these as issues for student nurses and by developing strategies to mitigate some of their negative or distressful impacts while enhancing more positive performance and learner enhancing effects (Chuan & Barnett, 2012:196; Sandvik, Eriksson & Hilli, 2014:288-289). The apparent supremacy of workforce culture over learning culture in practice indicates an uncoupling of practice and education, thereby creating a deficit in leadership of practice learning. Student nurses may sometimes be obliged to make up the deficit, for example by asserting their super-numeracy, but not all of them have the confidence to do so. It seems likely that this deficit can only be addressed seriously through working towards recoupling of education and practice (O’Driscoll, Allan and Smith, 2010:217).

The duration of clinical placement appears to influence the level of overall student nurse satisfaction, and how the quality of supervisory relationship and the pedagogical atmosphere in the clinical learning environment is experienced. Student nurses’ lack of familiarity with different clinical learning environments as a consequence of frequent and relatively short clinical placement periods require them to adapt to and “fit in” with a new nursing team regularly. These rotations do not provide ward staff with sufficient time to get to know individual

student nurses and to build a rapport with them. Furthermore, it seems that a student nurse who views the whole individual nursing process over a longer period, and with the same patient, is likely to gain a clearer understanding of a nurse’s role than one who has only participated in a series of disconnected tasks during a two or three week placement. In longer patient relationships, the student nurse could learn to recognise crucial elements of the caring relationship and also become aware of her or his own emotional reactions within such relationships (Chuan & Barnett, 2012:195; Tenza, 2015:45; Tiwaken, Caranto & David, 2015:71; Warne, Johansson, Papastavrou, Tichelaar, Tomietto, Van den Bossche, Moreno & Saarikoski, 2010:814).

The desire to return to certain nursing units after completion of nursing programmes seems to be the result of a prevailing culture of kindness and respect for patients, staff and student nurses. A culture of kindness and caring appears to emanate from the unit manager which in turn, attracts nurses with a like-minded approach to caring. This includes a supportive and proactive approach to teaching and supporting student nurses (Crombie et al., 2013:1284- 1286). Given the increasing difficulty in attracting and retaining a nursing workforce, it is imperative that clinical curricula and workforce policies are developed to ensure that student nurses are able to develop an understanding of their role, are successfully acculturated and assimilated into the profession and organisations, and acquire professional knowledge, skills and values from expert role models (Brown, Stevens & Kermode, 2013: 572).