Clinical learning of nursing students in Finland
In Finland, students study to become registered nurses for 3.5 years (210 ECTS) in universities of applied sciences. At the EU level, clinical practice covers at least 50% of the total degree. During their education and particularly in clinical practice situations, it must be ensured that nursing students are able to prepare their skills in evidence-based nursing (Ministry of Social Affairs and Health, 2012). There is a need for special learning situation arrangements in the context of health care and social services. Typically, nursing students carry out clinical practice as unpaid workers, acting as ‘extra’ persons in the workplaces, not included in staff resources. This is supposed to allow students a chance to have better circumstances for the placement and give them time for learning. One of the reasons that, for example, nursing students may not get opportunities to practice their competencies in their work as paid employees in the fact that, in Finland, nursing students are allowed to work as a fill-in for a registered nurse only once they have completed at least 140 ECTS of their nursing studies. The law contains many restrictions concerning health care and social service workers who have not yet graduated regarding what they are allowed to do in their work.
For instance, if the nursing student is allowed to perform some task during his or her clinical practice before reaching certain level of studies, they must be accompanied by an employee qualified for the task, who in turn shall take the responsibility of guiding the student to conduct the task in an appropriate and safe way. Registered nurses, referred to as the students’ mentors, guide and assess nursing students in the clinical practice situations; however, in Finland, university-educated teachers are also responsible for guiding and assessing the students during their clinical placements (Ministry of Education, 2006).
Nursing students must be trained to meet medical standards and have competence in nursing diagnoses and interventions (Eriksson et al., 2015). However, according to Kajander-Unkuri et al. (2013), specific competence areas in nursing are yet to be defined in the European Union. For example, Gardner, Hase, Gardner, Dunn & Carryer (2007) have argued that there are limitations to the use of a competency-based assessment: Nurses may have knowledge accumulated through education and experience, but they may nevertheless be unprepared to use it in their clinical practice actions. The nursing students’ capability describes their ability to use their competencies in novel as well as familiar circumstances. Rochester, Kilstoff & Scott (2005) found that while capability in technical skill is required in successful practice as a nurse, the capabilities of social and personal ‘emotional intelligence’ are also significant. The highest-ranked item in Rochester et al.’s (2005) important study was the interpersonal aspect of emotional intelligence, which was defined as ‘ability to empathize and work productively with people from a wide range of backgrounds’. Mentors in clinical placements spend a lot of time with students, which puts emphasis to their ability to assess how the students manage combining theoretical knowledge with the real word of nursing.
Verkkovirta project and nursing students’ learning by working
The goal of the Verkkovirta project, financed by the European Social Fund, is to develop new models that allow students to earn study credits from daily work. Haaga-Helia School of Vocational Teacher Education coordinates the project, while the subprojects are implemented in Saimaa and eleven other universities of applied sciences. (Verkkovirta 2016.)
Competencies required by a degree in nursing can be obtained both in the classroom and in the workplace. Therefore, new innovative methods are needed. In different fields of education, there is a need for different and novel arrangements of education. Indeed, this project has excellent potential to develop good practices that combine work and study. When nursing students obtain study credits for their daily work as employees, it must be ensured that successful practice is underpinned by the graduates’ ability to integrate and consistently apply a number of capabilities beyond profession-specific skills and knowledge. For example, Bisholt et al. (2014) and Stayt & Merriman (2013) have argued that nursing students may not get consistent opportunities and experiences of clinical skill development in their clinical placements, which may have consequences on nursing students´ learning and competency development. This might cause difficulties in placing students effectively in clinical contexts to ensure maximal learning opportunities (Walker et al., 2011). Through the placements, nursing students get to work in very different kinds of hospitals, nursing homes, home care etc. It is challenging to analyze what kind of possibilities they have during these placements to achieve certain kinds of competency and what is the level of these competencies.
Managers’ perspectives of the possibility of earning money and completing a degree at the same time
One of the roles of Saimaa University of Applied Sciences in the Verkkovirta project was to investigate working organizations’ perspectives of development needs in situations where students are able to receive payment for their work while at the same time have possibilities to build their competency for degree purposes.
Data collection and data analysis
Ten managers in different kinds of health care and social services (public, private and third sector) were contacted by visiting them personally at their workplaces. The purpose of the visits was to find out about the managers’ opinions of this aim. Interviews were held as dialogical discussion sessions, and the author was taking notes at the same time. After each interview, the notes were supplemented by the author to make them more accurate. The written data were analyzed by content analysis and themes were formed by combining the managers’ conceptions of the development needs related to this new way of earning money and studying at the same time in clinical situations.
Permanent worker as a nursing student
It has been common in nursing and social service organizations that when a worker holds a permanent position, he or she might get opportunities to combine some of their studies in higher education with their current job, getting to complete some study assignments, such as clinical practice periods or theoretical tasks at their workplace. For example, if the student has been working in a hospital or home care as a practical nurse, they can complete parts of their registered nurse education at the same workplace. The interviewed managers reported that they support workers who want to advance their studies in health care or social services. In some cases, workplaces may even have offered to change the student’s job description to provide them with more opportunities to use the working periods for educational purposes during the education. The support of colleagues plays an important role, as such arrangements may also effect the entire workplace. Managers highlighted that the main responsibility of employees is to perform their normal tasks at the workplace, and situations supporting the education may be arranged if the main work situation allows this without any major problems. The main focus must be on clients and patients, not just educational purposes.
The managers suggested that it is easier to manage simultaneous work and degree-earning when the worker conducting studies is has a permanent job contract. Nevertheless, managers also planned and provided options for temporary workers to combine their work and studies, for example, in some cases, work tasks could be arranged just for a given student. For example, a nursing student may have a summer job in home care of which, each week two or three days could be arranged to include certain type of work for the mere purpose of helping the student reach the level of competence required by their degree. Managers described that this might influence the students’ motivation as workers in the organization not only during the work practice period, but also later. Most of such arrangements could be facilitated by a multi-professional workplace where there are employees working in the profession pursued by the student. In fact, the managers highlighted the possibilities for students to collaborate with professionals during their work practice periods and the fact that it is not always possible if they are paid workers and not the ‘extra people’ as students with no financial impact to the organizations as usually.
Especially in small working places, the managers also brought up the question of the mentor having the ‘same profession as the student. Educational institutes typically require for the workplaces where health care and social services students practice their skills of competency to provide the student with a mentor in the same profession as the one which the student is working towards. Mentoring could also be arranged at times by providing multi-professional mentors; however the mentor who bears the responsibility of the student’s final assessment at the end of the clinical practice period should be in the profession as the one for which the student is studying. Managers shared the opinion that it should also be possible that, for example, a registered nurse should be allowed to assess a physiotherapist student’s ability to work in certain circumstances. The question of the managers was that ‘what is the problem of the multi-professional assessment’.
In order to successfully combine work and achieving competency for educational purposes, the importance of proper guidance and mentoring was highlighted. The managers argued that it is important for mentors to have more knowledge, for example, of the nursing education curriculum and skill requirements set for nursing students. There was also an apparent need for mentors to enhance their skills in assessing nursing students’ competence in clinical situations. Therefore, there is a need for instructions from educational institutes to the work placement sites. The main question seems to concern timing problems: mentors have a lot of responsibilities in their work settings and there are few resources for substitute employees. Therefore, it may not be easy to set time aside from patient care in order to study nursing student’s learning and assessment needs. In addition, if the registered nurses do get the opportunity to participate in training, they prefer to enhance their patient care knowledge, especially in case of nursing in specific fields (e.g. surgical or mental health nursing). Nursing guidelines and techniques are constantly in progress, and nurses are required to stay updated on these important issues, which also explains the order of importance for using nursing resources for education purposes.
Mentoring education arrangements
When asked about good practices for mentoring training, managers suggested events that would take only three to four hours in the evening and offering the same contents twice on different days would enable as many as possible to participate in the education and using necessary shift arrangements to take care of clients and patients. Managers argued that it would be easiest to arrange mentoring training at the work organization so that the workers would not have to travel a long way in order to attend, and it would also be ideal if the events were held at the working places of the mentors.
Support from teachers
It has not always been possible to ensure that mentors have completed mentor training, which makes the support of the students’ teachers even more important. The managers highlighted that teachers should visit the clinical placements in the beginning of the working period so that the mentors and students get orientation to the clinical practice period and the assessment process, including determining what the student should learn and what competency levels should be reached for educational purposes during the working period. Teachers should also clarify the responsibilities of each party: what should managers/organizations do, what is the student responsible for, what are teachers/educational institutes’ responsibilities? Managers also highlighted the role of the students: they may have broad responsibility of the whole process and must be particularly proactive in arranging and ensuring that they get possibilities for learning and earn the level of competency set for their degree. According to the managers’ views, the students who are willing to be active in process are more likely to take care of their own learning and related situations. This may help them graduate earlier than other students or possibly enhance their financial circumstances during their education.
Independent working situations
The issue of mentoring in independent working situations was also highlighted by the managers. Health care and social services involve certain situations that require employees to work by themselves, without any help from colleagues at the worksite. Home care and work conducted alone with the customer/patient in an examination room are typically one-worker jobs. Working alone is usually an outcome of limitations to financial and timing resources. What consequences could there be for student nurses needing to have someone to accompany them so that they could assess their behavior in real customer/patient situations? Would the rest of the employees have to work more because one of the workers cannot work independently all the time? This could also affect the willingness for the aforementioned arrangements at the whole work place and among workers.
The managers had a very positive view on improving students’ ability to earn study credits from their daily work. They had often witnessed students having to work during their studies to earn money to in order to support their family, small children or meet their financial needs. This might cause a delay in the students’ education, but the employers would like to employ this specific student after graduating and this is not possible because of the situation. The managers consider that combining work and studying gives ‘good drive’ to the whole workplace because the students may be highly motivated to improve the circumstances of working processes. In many cases, the students take on theoretical tasks, such as a final thesis, for certain work place needs.
Students’ ability to work in the ‘real world’ is very important for their professional growth by combining their theoretical knowledge with actions in a workplace. These learning situations are important, but it is also crucial that students increase their knowledge of their competency as nurses or other professionals. Final assessment in clinical practice during nursing education is extremely import for ensuring the sufficiently high quality of nursing graduates. In every profession, awareness of what employees know and do not know, and their ability to identify what they need to know is key to lifelong learning and becoming a better professional (Gardner et al., 2007). For example, Blackman et al. (2007) and Lauder et al. (2008) have argued that nursing students’ self-assessment skills may be insufficient and that self-assessment might thus not be a reliable method for ensuring the competence of nursing students. The challenges in combining work with earning credits to a degree also highlight this challenge of assessment. What are the circumstances in which students are working; what are the utilized competency areas, are the students able to do practice everything required by their studies, how is mentoring arranged, and how do students get relevant feedback and assessment?
Mentors are clinical nurses who supervise and assess nursing students during their clinical practice. Therefore, mentors play an important role in identifying nursing students’ capability (Jokelainen et al., 2011). If working organizations had possibilities to ensure that students get proper learning opportunities with the help of good mentoring and appropriate assessment practices, we could ensure meeting the objectives set for nursing students also in a situation when a student is paid for work during the period they learn nursing skills. In many other education sectors, it is not uncommon that students receive payment for their work also when the aim of their work period is to meet objectives set for their studies.. For example, in technological education in Finland, students are encouraged to get a summer job to earn credits for their studies. In contrast, in education in the field of health care and social services, students are typically considered to be unable to learn enough if they are working as paid workers. But again: high quality assessment is the way to ensure high quality of learning.
Educational institutes must carry out good teamwork with clinical practice placement sites and mentors to ensure high quality in the assessment process, especially when nursing students are also employees at the sites. This is a challenging set of circumstances because it differs from typical arrangements for nursing students’ clinical practice periods where students are perceived as ‘extra’ persons in the working places. The role of nursing teachers in the clinical placements has been sometimes debated, while findings by Helminen et al. (2014) and Löfmark et al. (2012) showed that nursing students and mentors rated highly the supervision they had from teachers. The opinions of the managers who participated in this inquiry belonging to the Verkkovirta project were similar. Mentors need support from teachers to improve the clarity of assessment plans and documentation: what nursing students are required to complete and explanations regarding the meaning of the ‘pass’ and ‘fail’ grades. Mentors and nursing teachers have their own roles in the clinical placements: mentors are the experts on clinical practice, while teachers´ role includes familiarity with learning outcomes defined for clinical practice and how these can be reached and assessed (Collington et al., 2012; Broadbent et al., 2014; Helminen et al., 2016). Therefore, nursing teachers’ visits to clinical placement sites for ensuring that nursing students get an opportunity to receive feedback on their performance from mentors are important for the good quality of the assessment process. Work organizations play a central role in enabling this special opportunity for students to arrange their studies in personal ways and, therefore, educational institutes and teachers should also invest in and carefully consider employers’ opinions and make this cooperation as good as possible.
The purpose was to investigate perspectives in work organizations on development needs related to students combining work and studies. By interviewing managers, we gained important knowledge that can be used in developing educational situations to provide students with opportunities to study flexibly and graduate within the appropriate timeframe. The importance of support and arrangements for the entire workplace and employees is highlighted. Finally, educational institutes must also guarantee that the teachers provide support to the students, mentors and managers during the process.
Kristiina Helminen, Saimaa University of Applied Sciences, Senior Lecturer, MHSc, kristiina.helminen(at)saimia.fi
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