Preparing students of nursing for Real practice
Frances White
University of South Australia, Whyalla campus, South Australia
frances.white@unisa.edu.au
Pamela Shackleton
University of South Australia, Whyalla campus, South Australia
pamela.shackleton@unisa.edu.au
Abstract: Educating for entry into the professions is not an easy task; on the one hand, the teaching methodology used
in the classroom and clinical laboratory is quite different from the teaching/learning methods used in the workplace,
and on the other, the learning that occurs within the educating institution is often seen, by the learner, to be unrelated
to that which comes about due to personal experiences within the ‘real’ world of professional practice. It has been
suggested by students and employers of nurse graduates that university programs devalue clinical learning and that this
may contribute to poor performances of graduates within the clinical area. The value of assessing skills within
university clinical laboratories is also questionable, as students find it difficult to transfer knowledge gained to real-life
situations and workplace contexts. Clinical Performance Assessment based on the Australian Nursing Corporation
competencies and the use of reflective journals to allow students to identify leaning needs continue to fragment practice
knowledge and fail to capture the essence of clinical practice. To overcome these issues of how to assess clinical
competence, a group of nurse lecturers teaching within the final year of a three year undergraduate degree, and
clinicians for the local health service, combined to devise an assessment using scenarios and problem based learning
strategies to overcome some of the issues identified, and to increase the practice knowledge and clinical ability of
graduating nurses.
Keywords: practice knowledge; theoretical knowledge; ‘real’ world of nursing; problem-based learning;
clinical reasoning skills; confirming and disconfirming clinical problems.
Introduction:
There is probably not a lecturer teaching within the professions who has not heard the words ‘but in the real
world’ or ‘when I was on placement …’. The ‘real’ world to the student is the one in which they desire to
practice their profession and, therefore, what happens in this world is important to them and they take notice
of it in all its glory and trepidations. This world is full of diverse experiences and complex learning
situations, and it requires the worker to synthesise and analyse information gleaned from a multitude of
sources. This is a world in which the worker must think laterally, make decisions quickly, take risks,
prioritise care needs and act as part of a multidisciplinary team. In this world workers have to trust their
knowledge, be creative, adaptive, flexible and competent. This world is usually fast-paced compared to the
relatively slow, mono-learning and single tasks emphasis within a relatively inactive classroom. The real
world is the one in which students test and refine their skills and knowledge, and they use the opportunity of
clinical experience to make a judgement about the suitability of their learning. For this reason, the ‘real’
world of professional practice cannot be ignored. Rossman (1999) believes that “Lecturers have a
responsibility to integrate high-quality academic and scholarly work with professional relevance and
application”.
Health agencies expect graduate nurses to demonstrate an understanding of the role and responsibilities of
the Registered Nurse, and to be competent in some essential areas of nursing. For instance, they expect that
the graduate will be competent in the fundamental skills of nursing, documentation, medication
administration, time management, and client assessment along with efficiency in the setting up and continual
management of some equipment, for example, IV equipment, patient controlled analgesia and ward
emergency equipment. It is increasingly obvious that within the ambiguity of professional practice today,
nurses are required to demonstrate multiple abilities and well developed competencies in order that they may
cope with all that happens during a shift. Within this ‘real’ world, the worker is assessed continuously,
indiscretions are not tolerated, and what one does within a hairs-breadth of time, may impact on their entire
professional life. Universities teach the knowledge and skills necessary for the student to work at a beginning
level, but the learning and the evaluation of the learning is often done in incremental steps over a whole
semester and the assessment of the depth of learning, that is, assignments, takes weeks to prepare.
Traditional styles of teaching and assessment of learning have not been successful in ensuring that a
graduating nurse can work effectively within diverse clinical settings, and this is expected of a beginning
Registered Nurse working within rural communities. For many years employing agencies situated in rural
Australia have raised concerns about the suitability of nurse graduates to work within, and to keep pace with,
the complexities of nursing practice (Williams 2000). According to Antepohl and Herzig (1999) if problembased learning is used “Students perceive their learning as relevant … [and clinicians have judged them]
better regarding their clinical knowledge and skills.” It is speculated that this is because students are more
involved in the care of the client even though the client and the clinical problem is fictitious and the problem
solving is not actually carried out within a clinical situation. Using the work of Boshuizen and Schmidt
(1992) and Eisenstaedt, Barry and Glanz (1990) these authors also point out that students who have been
taught under the model of problem-based learning are better prepared to transfer knowledge, more able to
apply principles to clinical practice and are “… better prepared for life-long learning”. Problem-solving
exercises are usually given to students in the form of scenarios or a small vignette, followed by a number of
questions that come from the lead-in. However, as Botti and Reeves (2003) have identified, the depth of
problem solving, reasoning and decision-making that come from the exercise is dependent upon the depth of
analysis and resource utilization required in the exercise.
What is the problem?
Boud and Syme (2000, p.37) points out that “The kinds of knowledge generated in workplaces may differ
greatly from those generated and sustained by academic institutions,” and this is partly due to the differences
of purpose and role of each institution (educational and hospital) rather than incorrect preparation of
students. Students often question the knowledge academic institutions expect, when through clinical
placements, they feel that the knowledge expected of them to practice is different, and that this difference is
more attuned to what they aspired to be when entering the program. Heslop, McIntyre and Ives (2001, p.627)
believe that the dichotomy lies in the perceptions students have of each environment. Students view the
academic setting as a teaching and assessment setting, while the hospital is viewed as a practice setting
where they can apply and hone skills and procedures previously only demonstrated and practiced within the
clinical laboratory. The academic setting is where they explore new theories, research and debate conflicting
and contrasting evidence to understand and support concepts, whereas the clinical setting is where there are
routines, set practices and a purpose for performing procedures and giving care. In academic settings
students of the same discipline and of the same year and knowledge level work together to get a set task
completed, but the ward is where different disciplines come together to care and cure a client and where the
learning is random, diverse and often unexpected. Furthermore, the academic setting is where care and
helping is only a concept, whereas in the clinical area, students can see the need for and the benefits of their
caring and helping attributes, and it is this, more than marks, which give them the joy and highs of being a
nurse.
Health agency perspective
Overall, clinicians within the area services by the university, felt that the graduates were not incompetent and
that generally, their practice was safe and appropriate at their level of experience, but while their practice
was, in the main, competent, at times their actual performance or abilities belied this level of apparent
competence. This, they believed, was more apparent when the ward was busier and it seemed that multiple
tasks confused the graduate, and the graduate had to perform procedures more-or-less independently. These
were procedures the graduate had done previously under the watchful eye and careful direction of another
Registered Nurse, so they were not new skills or skills that they had not had a chance to practice. Another
area of concern was that the graduates were not comfortable if they were interrupted or had to change their
carefully planned work; they constantly needed support, direction and reminding to complete skills and care,
and other RNs felt that they had to check up on them before the end of the shift.
The local health agency employed a number of the University’s graduating students and it was also a major
health agency in which students gained their clinical experience through placemen;, hence a number of third
year students who attended this agency for their final clinical placement were employed as Registered Nurses
(RNs) on completion of their course. Concern was expressed over the obvious discrepancies that existed
between the clinical assessment students gained during their final semester and that gained only 2-3 months
after commencing their graduate year from the same institution and, sometimes, from the same Registered
Nurse. Chang and Hancock (2003) suggest that this could be due to role ambiguity when the expected work
and role of the RN, and personal perceptions of themselves as a RN and nurse, collide with the actualities of
working and being a nurse who is now Registered. These authors also emphasised that there are
incongruencies existing between values and ideals of nursing which have developed during their
undergraduate degree, and those that confront them once they are employed to work as a Registered Nurse.
Greenwood (2000) points out that this occurs within the first 3-6 months while the new graduates are still
learning their, and other professionals’, roles and responsibilities.
Student perspectives
Lecturers are always interested in how their students cope with the work of being Registered nurse once they
leave the sheltered environment of the university. For two years the BN Coordinator kept in touch with a
group of ex-students during their first two years of working as Registered nurses. While this was not a
longitudinal study or even a research project, what students were saying about their university preparation
was supported by the literature. Students did not feel unprepared, just under-prepared. Students generally felt
that the ‘you are it syndrome’ was the hardest that they had to cope with. This syndrome is the sudden
realisation that you are now responsible and accountable for your own work and the work of the team, that
people are relying on you to make decisions and to guide them of the most appropriate action, where the
ward management is now your responsibility, and you have to actually speak to, inform and sometimes
disagree with doctors. These ex-students quickly learned to build a network around them, primarily of others
in their university group, past lecturers, friendly RNs regardless of whether they were working on the same
ward and with other graduates.
The university’s perspectives
The university has used a number of different types of assessment the purpose of which was to test
knowledge and to ensure that students developed critical thinking and decision-making skills. The types of
assessments most commonly used for third year students were: essays, examinations, care studies, clinical
scenarios followed by short-answer and/or multiple choice questions, reflective journals, ANC competency
recognition and utilization, and clinical skill testing of stated procedures. An assessment mapping exercise
also found that the same types of assessments were used predominately for the same cohort of student.
Interestingly, this exercise found that there was little change in the degree of difficulty of the assessments
apart from giving more targeted questions and greater marks for some exercises, for example, preparation of
a care plan. An analysis of the assessments found a tendency to ask questions that were contextual and
confirming. Botti and Reeves (2003) point out that these types of questions give all the information
necessary to make a diagnosis and/or judgement, and there is no conflicting evidence, no need for hypothesis
generation or the necessity for the student to separate relevant from irrelevant information. While these types
of questions have their place in the first year and perhaps early second year of the program, by the time
students reach the final year of their program, it is hoped that they would have developed higher order skills.
Furthermore, Arocha, Patel and Patel. (1993, cited in Botti & Reeves 2003) identify the need for forward and
backward thinking in the development of clinical reasoning. Backward reasoning, states Thomas, Wearing
and Bennett (1991, cited in Botti & Reeves 2003) “… is most often associated with novice decision-making
because novices tend to deal with largely unfamiliar problems with limited related knowledge.” While within
a relatively safe environment such as that of a university, this type of reasoning is encouraged and practiced,
while within the ‘real’ world of nursing, and especially within rural health agencies, the expectation on the
graduate by the employing agency is that they have the ability to identify and use multiple reasoning
techniques to make a decision and clinical judgement. Unfortunately, the graduates believe that they have
appropriate decision-making skills because this is what the assignment results were telling them. They were,
therefore, going into the ‘real’ world of nursing blind, and the stress of not being able to trust selfknowledge, or know what the real problem was, led to confusion, hesitancy in applying knowledge, and
regression of motivation and independence and this led to a decreased competence.
Placement within clinical areas of professional practice, and the use of clinical laboratories, are not immune
from criticism. Williams (2000) points out that structured clinical placements often do not prepare students
for the ‘real’ work of nursing either. Although students spend more time in the clinical area during their final
semester, much of the ‘essential’ knowledge, that is, the medical and surgical knowledge, is taught in the
second year of their degree, and generally, students only spend 2 – 4 weeks on clinical placement in each
semester of their second year. This is not enough, according to clinicians and students, to consolidate all that
is taught, and furthermore, students attend their clinical placement with a number of skills to practice, and
this leaves them little time for other learning. The emphasis on skill acquisition to the detriment of holistic
nursing is a hindrance to student understanding of what nursing is all about. Clinical laboratories or skill
laboratories, while they provide a safe environment for the students to practice skills, “… ignore the
interpersonal skills which are an essential component of carrying out a clinical procedure” within a ward
setting (Kneebone, Kidd, Nestel, Asvall, Paraskeva & Darzi 2002).
It could be argued that nurse graduates are novices, but within nursing there are many levels of ‘novice’. For
instance, graduates working within their first ward would have a lower ‘novice’ status than someone who is
doing their fourth rotation; nurses return to the ‘novice’ status each time they change wards, especially in the
early stages of their career, when they change positions within the same institution or change jobs. The
difference appeared to lie in the ‘real’ world phenomenon; perhaps if we could mimic the ‘real’ world for the
students, their thinking, understandings and meanings of what nursing is would make the transition between
being a student and being a RN smoother.
The issue for nurse lecturers is how to simulate the world of nursing, one that provides the right mix of
realism and complexity, but also one which is conducive to learning and enables the development and testing
of practice knowledge. There needs to be a greater colligative approach to professional development, one
that combines the educational and health institutions, and it is this collaborative approach between how and
what we assess and evaluate and the expectations of students once they enter the professions, that leads to the
development of an assessment that better evaluated student capabilities and skill and prepared them more
thoroughly for clinical practice in the ‘real’ world of nursing.
The process
After some soul searching by the BN Coordinator, Clinical Coordinator and the Clinical Educator at the local
hospital, and having looked more closely at what the concerns were, and if these were supported within the
literature, a group of clinicians and third year lecturers met to discuss how the situation may be changed and
how the university can better prepare students for the ‘real’ world of rural clinical practice. Having looked at
the problem from the perspectives of the employing agency, the graduates and the university and having
searched the literature, the group made the decision that for the next group of third year students a
collaborative approach to assessment strategies would be developed and be incorporated with each
semester’s clinical course.
Following an analysis of the course offered at the university and the assessment done to ensure practical
competence and practice knowledge, the group decided to try alternative assessment and teaching strategies
that would enhance students’ confidence in their procedural performance, increase their knowledge about
practice, as well as prepare them better for professional practice within the ‘real’ world of nursing. The
university had used scenarios and narratives previously in the teaching and assessment of student learning
and abilities, but usually in the form of giving a scenario or narrative and then asking specific questions
(knowledge or procedural) about the care of the client or clients. However an assessment that mimicked the
‘real’ world of practice was something new and exciting. The assessment was not all that different from what
had been done previously except that we used the real-life experiences of clinicians to organise the practice
area, clinicians formed part of the assessment team, and each scenario was contextual and contained
disconfirming information. Disconfirming information, says Botti and Reeves (2003), are “… items of
information that lead to the formation of alternative hypotheses about the underlying cause of particular
problems.”
It was also decided to better prepare students more thoroughly for their graduate year and to reduce the sense
of not being able to cope due to lack of knowledge and ability. To this end, more emphasis was given to
interactive exercises during tutorial, workshops/clinical laboratory sessions and lectures, often through using
narratives or scenarios where the emphasis was not only on the procedure that had to be taught, but on
practice knowledge, that is, knowing about, when and how. In addition, in each teaching week a specific
attribute identified by students, clinicians, lecturers and the literature as lacking or poorly developed in the
graduate nurse, also formed part of the teaching week. These consisted of, for example, working within a
team, communication with other professionals, problem solving, client physical/emotional/cultural/mental
assessment, decision-making, time management, allocation and delegation, and documentation.
The scenarios written and prepared by the clinicians were a reflection of what the graduate could expect to
encounter within their first couple of months within a ward. Forms, client notes, care plans, medication and
fluid balance charts as well as any other charts (including Xrays) or test results were organised (maintaining
client confidentiality) by the clinicians, and the assessment tool based on performance competence, best
practice and Australian Nursing Council (ANC) competencies were organised by the university. The
assessment team consisted of university lecturers and expert clinicians and each would assess according to
their expertise and experiences. The assessment team varied because of time and number of students. To
ensure consistency of assessment, prior preparation of nurse lecturers and clinicians ensured common
understanding of the assessment criteria. The team consisted of nurses, although it was originally hoped that
other disciplines would take part, but this was not possible; however, clinicians took on different roles within
the team according to their experiences and expert knowledge and the scenario requirements. With the use of
laboratory models as the clients and one assessor as the main client, it was possible to have at least a senior
clinician and one other staff member (nurse or another health discipline), and possibly a family member for
each scenario. Each assessor evaluated the performance of the nurse based on the role that they played within
the scenario. Hence, students received feedback on their performance from at least three different
perspectives.
The scenarios took on the form of being problem-based in that there was a task students had to complete and
to do so they had to seek out further information and identify the problem. Each scenarios was a snapshot of
a ward at a particular time of the shift; for instance, the nursing hand-over, doctors’ rounds, medication
administration clients coming and going from theatre or diagnostic tests. Other assessors played out the role
of other staff or family, and their interruptions to planned care required students to make decisions on what
to do, and to prioritise quickly. The main emphasis of each scenario was that it provided students with the
opportunity to demonstrate their nursing skills at beginning level. While each scenario varied, each had to:
 closely mimic the ward environment for about 15 minutes of a shift;
 consist of four to six clients which the students were primarily responsible for during the shift;
 provide conflicting information requiring students to make a judgement;
 cover a situation where students were required to inform others;
 contain a situation where the student was expected to seek out further information from someone or
something, for instance, the senior nurse, family, client, lab reports, client’s medical officer, another
discipline health worker, pharmacist or client case notes, and
 contain, as its main focus, a task for the student to complete within the time frame.
The Outcome
All who participated, including the students, positively received the evaluation of the collaborative
assessment. Student evaluation of the courses emphasised that they felt they learned a lot during the
semesters and that the learning was more about what their role would be like once they graduated. However,
the real test was whether the students felt more able to cope with the ‘real’ world of nursing once they
commenced their graduate year. The first year this assessment was used, the outcome was a more confident
cohort of graduates as reported by many employing agencies, not just the local health services who
participated in the exercise. When asked why they were more confident, the graduates’ mentors, usually the
Clinical Educator, believed that they anticipated what needed to be done quicker and often without
prompting, they made suggestions about their client care rather than waiting for another RN to suggest
preferred or altered care. However, this group, generally, were more assertive in the classroom and usually
asked for what they believed the university should be delivering. In this sense, it was difficult to know what
the changes would have been without the collaborative teaching approach and if the results would have been
so remarkable. Students felt that the exercise given throughout each semester of their final year and the
collaborative assessments provided a safe zone, without being unrealistic and that it better prepared them for
the practice they expected once they commenced their graduate year. Students also commented on their
perception of clinicians as being closer to the ‘real’ thing and therefore, they felt that the assessment was
more realistic, Students also perceived clinicians as more ‘tuned’ into the ‘real’ world of nursing and having
them working within the teaching team and within the university environment provided a more realistic
environment in which students could test their knowledge and practice.
The second cohort of students was difficult to assess due to a breakdown in the structure and continuity of
the assessment process. One year on and all health agencies were drastically short of staff, and while the
clinical nursing group were still committed to helping and being involved in the collaborative assessment,
due to inconsistencies of staffing, they could not really commit to the process. This meant that lecturers had
to do the assessment. The outcome for the students was that they liked the exercise and felt that it was more
realistic to what they perceived to be actual practice. The benefits to this group once they commenced their
graduate year, was harder to assess. Health agencies did comment that they were more willing to be involved
in the work of the ward, and that they were a little more confident in their knowledge, but that overall, they
were not as well prepared as the graduates of the previous year.
The following year, the team broke up; lecturers taught other courses and the problems with short staffing
still existed for the clinicians. The teaching group decided to revert to what was done previously before this
project commenced. They did keep the specific content that was introduced each week during the third year,
but did not keep the assessment.
Regardless of this, however, it is evident that drawing on the students’ existing knowledge and skill, and
tinkering with the environment to make it more closely represent and feel like the world in which they aspire
to practice, does seem to affect students’ understandings of what they need to know within the world of
nursing. In order to enhance the transference of knowledge from the world of the university to the world of
practice it is evident that more than just the linking of theoretical knowledge to practice knowledge is
necessary. Rather, as this project demonstrated, students have to form a connection with the contextual
environment in which they are to practice in order for them to be able to take knowledge learned within one
world and apply it to another.
Conclusion
This exercise had many positive outcomes. The collaborative approach to the assessments development and
implementation enabled lecturers and clinicians to see the students act as they would as a graduate nurse, and
it identified many areas that both lecturers and clinicians could do to better prepare students for clinical
practice. For the lecturers it was the realisation that students do not always transfer knowledge from the
classroom to their work within the clinical ward in meaningful ways. The clinicians could see greater
benefits of students undertaking clinical placements rather than merely to practice procedures, and this led to
them ensuring that students received more learning time through questioning and reflection than they did
previously.
This project was mainly a problem solving one where consistent problems were identified and lecturers, in
the first instance, set out to solve them. It was not a formal research project. It is evident, though, that more
needs to be done on the ‘real’ world phenomenon. Students who view the university environment as ‘unreal’
may find if more difficult to adjust to clinical practice on completion of their program, than those who see
the interrelationships that exist between the roles the university and the clinical area plays in their education.
Johns and Freshwater (1998) have expressed the importance of anticipatory reflection and how this type of
reflection can be used to increase the learning and competence of students who have not experienced a ward
environment. Conversely, students enter nursing with some understanding of what a RN does, and they have
already formed a view of the knowledge required to get to this point and to work within this role. If the
university then fails them because they offer a different perspective of the role that requires a different type
and depth of knowledge and understanding, the student will develop role ambiguity and fail to adjust to the
role upon graduation easily.
This project also identified some issues concerning the types and depth of assessments used by the university
to test student knowledge and capabilities, and it made lecturers more aware of the difference between the
teaching of theoretical knowledge and practice knowledge; one does not automatically follow the other.
Although this exercise controlled the ‘real’ world phenomenon, learning strategies were easily identifiable to
the astute students. The issue that nurse lecturers, clinicians and students need to be cognisant of, however, is
that ‘real’ does not mean the only way of doing, nor does it offers only truthful, well researched and
evidence-based practices nor appropriate learning experiences all the time. It is evident that a degree of
discrimination and analytical reflection needs to be included within any ‘real’ world phenomenon that is used
as a learning exercise.
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