District nurses' experience of supervising nursing students in primary ...

Nurse Education in Practice 9 (2009) 361–366

Contents lists available at ScienceDirect

Nurse Education in Practice journal homepage: www.elsevier.com/nepr

District nurses’ experience of supervising nursing students in primary health care: A pre- and post-implementation questionnaire study Elisabeth Bos a,*, Anna Löfmark b, Lena Törnkvist a a b

Centre for Family and Community Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Alfreds Nobels Allé 12, 141 83 Huddinge, Sweden Department of Caring Sciences and Sociology, University of Gävle, Gävle, Sweden

a r t i c l e

i n f o

Article history: Accepted 12 October 2008

Keywords: Clinical supervision District nurses Students Primary health care

s u m m a r y Nursing students go through clinical supervision in primary health care settings but district nurses’ (DNs) circumstances when supervising them are only briefly described in the literature. The aim of this study was to investigate DNs experience of supervising nursing students before and after the implementation of a new supervision model. Ninety-eight (74%) DNs answered a questionnaire before and 84 (65%) after implementation of the new supervision model. The study showed that DNs in most cases felt that conditions for supervision in the workplace were adequate. But about 70% lacked training for the supervisory role and 20% had no specialist district nurse training. They also experienced difficulty in keeping up-todate with changes in nurse education programmes, in receiving support from the university and from their clinic managers, and in setting aside time for supervision. Improvements after the implementation of a new model chiefly concerned organisation; more DNs stated that one person had primary responsibility for students’ clinical practice, that information packages for supervisors and students were available at the health care centres, and that conditions were in place for increasing the number of students they supervised. DNs also stated that supervisors and students benefited from supervision by more than one supervisor. To conclude, implementation of a new supervision model resulted in some improvements. Ó 2008 Elsevier Ltd. All rights reserved.

Introduction Primary health care is considered as the foundation of nursing and health care in many countries; and will continue to be significant in the future (WHO, 1988). During training, all nursing students in Sweden come into contact with this form of care and are supervised by district nurses (DNs). The literature describes ways in which such supervision is undertaken in hospital wards and institutions (Andrews et al., 2006; Brammer, 2006). Knowledge of DNs’ qualifications for and interest in supervision in primary health care is limited (Gopee et al., 2004). The vital role that supervisors have in the support, supervision, and assessment of students during their clinical practice has been emphasised (Pellatt, 2006). The objective of supervision is to improve the nursing student’s ability to integrate theory and practice and to develop an understanding of patients’ need of care (Severinsson, 1998; Johansson et al., 2006). Quality of supervision depends on the competence of the supervisor and existence of a clear structure and content for their supervision (Andrews and Chilton, 2000; Löfmark and Wikblad, 2001; Papp et al., 2003). DNs, like all other supervisors, * Corresponding author. Tel.: +46 8 524 886 96; mobile: +46 70 484 56 45. E-mail address: [email protected] (E. Bos). 1471-5953/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2008.10.007

are dependent on various forms of support within the organisation – from the universities and their workplaces. Deficiencies, such as time for supervision, have been shown to have clearly negative consequences for students’ learning (Saarikoski and Leino-Kilp, 2002; Landmark et al., 2003; Dalton, 2004).

Background Due to various reforms at the end of the 1990s, nurse education in Sweden and several other countries has become a part of the higher education system, where integration of nursing knowledge into practice, development and research are salient aspects (Andrews et al., 2006; Björkström et al., 2003). Guidelines for the higher education in Sweden stress that students must obtain knowledge to develop the ability to make critical, independent decisions and the ability to differentiate, formulate, and solve problems (Svensk författningssamling, 1992:1434). For this to occur, supervisors must have adequate clinical experience, adequate theoretical and educational/supervisory competence and a critical scientific approach (Andrews and Chilton, 2000; Papp et al., 2003; Midgley, 2006). Supervisors are expected to adapt their teaching to needs and knowledge of individual students and to ensure that students are given the opportunities to learn various subjects

362

E. Bos et al. / Nurse Education in Practice 9 (2009) 361–366

(Ekebergh, 2001; Pellatt, 2006). With an education system in flux this is a challenge. A prerequisite for students being able to integrate theoretical and practical knowledge is a flexible, open learning environment in which students feel welcome (Saarikoski and Leino-Kilp, 2002; Lindgren et al., 2005). The supervisor must create opportunities for reflection (Benner, 1984; Ekebergh, 2001) and foster critical thinking and life-long learning (Lambert and Glacken, 2005). In the clinical environment, students should get the opportunity to monitor, plan the care for and observe the changes in patients’ health status and should be responsible for nursing interventions for some patients (Benner, 1984; Löfmark and Wikblad, 2001). Nurses often feel inadequate for the role of a supervisor, and many doubt in their ability to teach (Andrews and Chilton, 2000; Ekebergh, 2001). Studies show that in the recent decades, various functions and services were developed to meet the conflicting demands that supervisors experience and to close the theory–practice gap (Ekebergh et al., 2004; Ekebergh, 2005). Roles such as clinical education facilitator, practice educator and clinical placement coordinator have been introduced to give support to supervisors and students. As a result, supervisors and students received increased support. The teaching process became more effective, students improved in their ability to think critically and to reflect in practice, and they entered the nursing profession more quickly (Drennan, 2002; Lambert and Glacken, 2005; Jowett and Mcmullan, 2007). Literature has addressed specific issues related to clinical education, such as support for supervisors (Landmark et al., 2003), experience and knowledge for the supervisor role (Andrews and Chilton, 2000). However, relatively few studies have provided models to guide the development of effective clinical supervision. According to Gopee et al. (2004), knowledge of primary health care as a learning environment is limited. Because primary health care is an accepted setting for clinical training of nursing students and more and more patients will be looked after at home, detailed investigations of how DNs view implementation and organisation of student supervision are becoming more pressing. Aim The aim of this study was to investigate DNs’ experience of supervising nursing students in primary health care before and after the implementation of a new supervision model. Methods Study design A descriptive, quantitative design was selected (Polit and Beck, 2004). The study was conducted in one part of Stockholm County Council in Sweden.

2006). The teacher from the university is also engaged in the students’ clinical practice, and is expected to facilitate and support application of theory to practice and practice to theory (Gillespie and McFetridge, 2006; Taylor, 2007). This extensively used model is based on cooperation among supervisors, students, and teachers; it exists in Sweden and internationally and is used in primary health care and other clinical areas. The new supervision model was developed to meet some of the challenges in nurse education as part of a higher education. The preparatory work is based on the literature, in which the supervision takes on another more defined meaning (Cameron-Jones and O’Hara, 1996; Pellatt, 2006). Four factors are significant in this new supervision model: (1) one DN has organisational responsibility for the students and the structure of the primary health care allocation (contact person), (2) supervision is shared among two or more DNs to increase the student’s experience in patient care, (3) supervision is planned in order to assure students continuous caring experiences with some patients and (4) seminars are introduced at the health care centres to support the cooperation between university and primary health care and integration of theory and practice (results not reported in this study). The implementation included the formation of a network involving meetings organised by two clinical education facilitators for the DNs responsible for the students and the structure of the primary health care allocation. These meetings, 12 in total, concerned the new supervision model, educational and teaching aspects of supervision and assessment, and the structure and content of nurse education. Supervisors responsible for day-today supervision of the students were invited to participate in four of these meetings. The number of DNs participating at these meetings varied from 12 to 18. Participants A convenience sample was selected consisting of DNs and RNs who worked as DNs in 22 of 175 health care centres in one part of Stockholm County Council. The selection included regional and urban centres. Ninety-eight of 133 DNs (74%) at the 22 health care centres responded to the questionnaire (November 2003) before the introduction of the model and implementation of the networking meetings (from January to November 2004). Eighty-four of 130 DNs (65%) at 17 health care centres responded after the implementation (November 2004). The reasons why several DNs did not respond to the questionnaire despite a reminder included closure of a health care centre, and the DNs who had ceased their employment were on long-term sick leave, parental leave, or service leave. Some DNs failed to complete the questionnaire due to a high workload. All the DNs in the study were females. Their mean age was 50; on average, they had 24 years of professional nursing experience and 12 years of experience as DNs. Data collection

Setting Through division of the country in different county councils, which are geographical areas, and within these areas smaller catchment areas, served by a health care team consisting of DNs and physicians, the inhabitants are offered care by DNs either at the primary health care centre or in their homes. Nursing care is given to children, adults and older people (SOSFS, 1995:15). The traditional and the new supervision model The traditional method of supervision in nursing education is an agreement of one nurse, responsible for supervision of the day-today work of one student during the clinical practice period (Pellatt,

A questionnaire was developed based on the literature and the authors’ knowledge and experience. The questionnaire was pilottested and validated by 12 DNs, who were asked to consider the content, intelligibility, and relevance of each question. After some modifications, the final questionnaire contained 51 items. The questions had three response options: yes, no, and don’t know, or four response alternatives: to a very high degree, to a quite high degree, to a quite low degree, and not at all. Space was provided for personal comments. The questionnaire covered the following areas: 1. Background, capabilities, skills: 12 items (age, previous education, work experience, and supervisory experience).

363

E. Bos et al. / Nurse Education in Practice 9 (2009) 361–366

2. Performance of supervision: 25 items opinions about the opportunities to supervise students; number of students; time and planning; opportunities for keeping up-to-date changes, for students to follow a limited number of patients, for reflective supervision, for passing on knowledge; and opinions about the confidence in the profession and as a supervisor, about the supervisory role, and about support from the university, the clinic manager, and colleagues). 3. Organisation of supervision: 14 items (whether there was a contact person with the primary responsibility for the clinical practice of students and for the quality development of clinical practice, information packages, introduction letter, written plan for the students’ clinical practice, how supervisors were chosen, the number of students allocated or the number it was felt possible to allocate to a supervisor, number of supervisors per student, whether there were benefits to a student being instructed by several supervisors, assessment of students, and whether DNs were allocated special time for supervision).

Table 1 DNs’ year of entry into the nurse register, educational background, and responsibilities. Background and competence

Before (n = 98)

After (n = 84)

p

n

%

n

%

Registered nurse Registered nurse < 1993 Registered nurse P 1993 Total

85 13 98

87 13 100

68 16 84

81 19 100

.32

Educational background Specialist district nurse training Clinical supervisor training – 5 points Clinical supervisor training – 10 points Other pedagogic training

78 27 3 15

81 30 5 22

66 23 5 13

79 30 9 23

.87 .94 .42 .96

Primary responsibilities Home nursing only Clinic nursing only Both home care and clinic nursing Other responsibilities besides those listed above

10 20 64 25

11 23 81 40

6 23 54 31

8 29 70 57

.44 .38 .48 .03*

*

Statistically significant difference at a = .05.

Procedure DNs at the health care centres received a written request to participate in the study. The participating DNs were given verbal information by the two clinical education facilitators before the questionnaires were distributed. One DN was charged with the task of issuing and collecting the questionnaires at each health care centre. The questionnaires were collected in a sealed envelope, and were sent to an independent person for data processing. Data were thereafter entered into a database and analysed. The same procedure was used for the pre- and the post-implementation questionnaires. Ethical considerations The DNs participated voluntarily, and informed consent was obtained. Confidentiality was ensured using an independent person for de-identification. The Ethics Committee at Huddinge University Hospital, Karolinska Institute approved the study (registration number 508/03). Data analysis Calculations of distribution frequencies and percentages were made in STATA, version 9 (StataCorp LP College Station, Texas, US). Tests for the differences in the mean values before and after the implementation for different variables were done in StatXact, version 6.3 (Cytel Software Corp., Cambridge, US). Exact p-values for differentiating the groups from the common median were calculated in a two-by-two table using the Wilcoxon–Mann–Whitney test, assuming independence between the groups. Testing for the differences in distributions of different variables before and after the implementation was done in StatXact, version 6.3, assuming independence between the groups. Exact p-values were determined using the Wilcoxon–Mann–Whitney test for two-by-two tables and the Kruskal–Wallis test for larger tables. Statistical significance was accepted if p < .05. Results Background and competence Table 1 presents the professional experience of the DNs. More than 80% of the DNs graduated before 1993. Most DNs worked in

the clinic and in patients’ homes. About 20% did not have formal district nurse training, and about 70% did not have formal pedagogic/supervisory training. A higher percentage of DNs worked with other home nursing and clinic nursing. About 65% of the DNs had in average supervised three students both before and after the implementation (data not shown). Performance of supervision About half of the DNs were allocated, and felt it was possible to be allocated, one to two students per supervision period. Differences between the estimates made before and after the implementation, regarding the number of allocated students, were non-significant, as were the number considered possible for the allocation. More than 90% of the DNs felt that there were opportunities to reflect on patient situations with the students and to convey information on the overall aim of primary health care and its function and how various professional disciplines, departments, organisations, and other caregivers cooperated (Table 2). Around 80% felt that conditions allowed supervision of students in the workplace, and that supervision was a part of the clinical role. About the same amount considered that there were conditions for planning the content based on students’ individual needs, students followed the care of a few patients, and there were conditions for achieving examination assignments, i.e. objectives for primary health care and cooperation between caregivers. But less than half thought that conditions allowed them to remain conversant with the changes in nurse education and to set aside special time for supervision. Compared with before the implementation, a greater percentage (61%) of DNs thought that conditions for supervising more students did exist (p < .01). For about 80–90% of the DNs, pre- and post-implementation determinations revealed that they felt confident in their professional role as DNs and as supervisors, that their professional role was clear and evolving for them, and that they received support from their colleagues (Table 3). But the DNs thought that they received less support from colleagues after the introduction of the model, compared with before: 78% vs. 91% (p < .02). About half of the DNs thought that the university and their clinic manager supported them in their supervisory role, and that their knowledge of current nurse education was adequate. Differences in these findings pre- and post-implementation were non-significant.

364

E. Bos et al. / Nurse Education in Practice 9 (2009) 361–366

Table 2 DNs opinions on prerequisites for supervision of students in the clinical setting. Results are presented as number (n) and percentage (%) of those who responded ‘‘to a quite high degree” and ‘‘to a very high degree”. Performance of supervision

Are conditions in the workplace conducive to: . . . supervising the students who are receiving their clinical supervision in the clinical setting . . . supervising a greater number of nursing students . . . supervising as part of your clinical role . . . setting aside special time for supervision . . . planning the content based on students’ individual needs . . . keeping up-to-date with changes in nurse education . . . letting students follow the care of a small number of patients . . . sharing reflection on patient situations with the students . . . assisting and giving the students advice to complete the examination assignments . . . conveying the main objectives of primary health care . . . conveying to students how primary health care functions . . . informing the students how cooperation between various clinical disciplines works . . . informing the students how cooperation occurs between various departments and organisations and other caregivers *

Before (n = 98)

After (n = 84)

n

%

n

%

80 12 61 42 72 29 71 87 75 87 90 89 84

90 14 79 55 82 36 77 94 83 95 97 95 90

72 48 53 29 62 30 58 72 60 74 77 79 72

88 61 79 44 81 45 74 92 77 93 96 98 91

p

0.67