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Thursday Review: “Nursing students’ socialisation into practical skills”

Mona Ewertsson, Sangeeta Bagga-Gupta, and Karin Blomberg noticed that there is precious little data available on how nurses move from the academic knowledge of their profession into its clinical practice. Much of the literature on socialisation in nursing has focused on describing negative experiences that shape the socialisation process, they write in Nurse Education in Practice.

Socialization, the authors cite, means that nursing is more than just knowledge and skills, it’s the development of an identity1 around a vocation. They identify four key elements to it:

  1. a reflective approach based on a theoretical framing
  2. multitasking situations
  3. shifts in an active role as a nursing student, and
  4. styles of supervision.

Of the four, the first seems to be the key to the others.

The study was carried out in an emergency department, where multitasking is vital. The authors point out that “multitasking” includes patient interaction, that multitasking includes situations where, alongside the performance and training of practical skills, the patient, as well as their relatives, need to be responded to.

By “shifts in an active role”, Ewertsson et al. mean the nursing student’s shift from knowledge of a clinical skill to the independent practice of it. The nursing students the authors studied expressed appreciation of being given these frequent [learning] opportunities, and communicated their desire to repeatedly practise skills, even though the clinical practice environment is the most substantial factor for stress among nursing students.

The “styles of supervision” Ewertsson, et al. write about refer back to what extent the “preceptors” actively communicate about the clinical skill the nursing student will be doing, the student’s understanding of it, and how ready the student feels they are to do it safely and effectively. This is the difficulty in supervising nursing students:

To be successful in something that is emphasised in the group that one is becoming a member of, increases the feeling of belonging to the group.2 However, in this respect it is important that the student understands what the concept “to be successful” in performance of practical skills means. In some situations in this study, the students performed practical skills and appeared not to understand that their performances were not carried out safely, thus jeopardising the patients’ safety. When a student lacks proficiency, the preceptor has an important role to identify this, and to support the student, but also to protect the patient.

Examples of reflecting (or not)

Ewertsson, et al, then, spend most of the article talking about the importance of reflection and theoretical discussion without a discussion of how that reflection can be structured. Here are two examples from the paper, the first with no reflection or discussion, and the second presented in the article as an Example of theoretical reflection — before and after an event:

An intravenous (IV) injection has been prescribed.

“You take care of it,” says the preceptor (P) to the student (S). The S has not been taught this subject in her curriculum, but says nothing. They go to the drug room to prepare the injection. S cannot calculate the correct drug dosage and she fails to transfer the drug into the syringe correctly. She does not know how to eliminate the air that has seeped into the syringe. P has to correct all these mistakes. They enter the patient’s room without discussing how an IV injection should be prepared. In the patient’s room, where more staff are present, P says, “Lift up that pink hat; there you should flush and give everything.”

S cannot open the “hat” and also doesn’t understand the relationship between flushing and giving drugs.

When they leave the room, P asks, “Have you ever done this before?”

“No,” answers S.

“OK, replies P. No further discussion ensues on what has happened.

Contrast that example with:

The preceptor (P) says, “We’ll give oxygen to a patient with chronic obstructive pulmonary disease through a nasal cannula. What do you think of that?”

“I know it can be dangerous,” responds the student (S).

“What do you mean by dangerous?” asks P.

S does not respond. P explains the risks using simple language, and invites questions. Then P asks, “How do you plan to place the nasal cannula, and why?”

S answers, “It should be placed in the right direction in the nose and fastened behind the ears.” They enter the patient’s room and S applies the nasal cannula correctly but fastens it very tightly under the patient’s chin. P loosens it directly but says nothing inside the patient’s room. Once outside the patient’s room, P asks, “How do you think it is for a patient who has shortness of breath when you fasten it so hard under the chin?”

They then reflect on and discuss this issue.

The example in which the preceptor took the time to engage the student is a classic example of story structure being used in communication.

The student, the preceptor, and the story

Stories start with problems and proceed through obstacles until a solution is found that everyone in the story can accept.

This preceptor-student interaction begins with the search for a problem. The preceptor clearly wants to see if the student can articulate what the problem might be: “What do you think of that?” When the student offers a problem that the preceptor doesn’t find specific enough, the preceptor pushes for more information, “What do you mean by dangerous?” and when the student doesn’t know, the preceptor explains it “using simple language”.

Now that the problem with placing the nasal cannula has been stated, the preceptor wisely tries to overcome an obstacle early on: “How do you plan to place the nasal cannula, and why?” This appears not to be an issue, and the placement commences.

There’s an additional obstacle, though: the student places the cannula correctly, except for the tightness under the chin. The preceptor didn’t correct the student right away, but simply adjusted it, and then discussed the placement of the tubing with the student outside of the patient’s earshot. Notice that the preceptor again searched for a problem: “How do you think it is for a patient who has shortness of breath when you fasten it so hard under the chin?”

Even in this simple narrative from a teachable moment, several interwoven stories emerge:

  • Does the student understand how to place a nasal cannula safely?
  • Can the preceptor make the patient comfortable after the cannula’s tubing was placed incorrectly?
  • Can the student be made aware of the patient’s need for comfort?

Each one of these stories has a beginning, a middle, and an end. That is, each one of these stories has a problem, an obstacle, and a solution:

  • Does the student understand how to place a nasal cannula safely?
    1. Problem: The preceptor is unsure if the student knows how to place a nasal cannula correctly, safely, and comfortably.
    2. Obstacle: The student can’t specifically articulate what’s dangerous about placing a nasal cannula.
    3. Solution: The preceptor explains the pitfalls in simple language and invites questions.
  • Can the preceptor make the patient comfortable after the cannula’s tubing was placed incorrectly?
    1. Problem: The student has tightened the cannula’s tubing too tightly.
    2. Obstacle: The preceptor must make the patient comfortable, and doesn’t wish to alarm the patient or belittle the student.
    3. Solution: The preceptor loosens the tubing themselves, and waits to discuss it.
  • Can the student be made aware of the patient’s need for comfort?
    1. Problem: The student doesn’t understand that they’ve made an error placing the cannula.
    2. Obstacle: The preceptor must make it clear why the student’s skill must be corrected and how.
    3. Solution: The preceptor asks the student to reflect on their specific placement of the cannula, and how it might affect the patient’s health and comfort.

The only real “dramatic” choice made here is the prefector’s decision not to correct the student in front of the patient, but to do it outside of the patient’s hearing. I assume this is for the patient’s peace of mind, as well as the student’s ego.

These stories are simple enough, and none of them is very long, but it demonstrates the structure of the reflection and discussion which Ewertsson, et al. are talking about. That reflection and discussion centers around the potential problems before, the mistakes made during, and the consequences of those mistakes after the skill is performed.

This problem-finding ability is the key to the reflective approach to learn to implement new skills, which layer on top of one another to form a nurse’s multitasking ability, forms the most important questions as a student takes on increasing amounts of independence, and is the most valuable tool a preceptor holds to teach the students in their charge.

Sources

The article reviewed: Ewertsson, Mona, Sangeeta Bagga-Gupta, and Karin Blomberg. “Nursing Students’ Socialisation into Practical Skills.” Nurse Education in Practice 27 (November 2017): 157–64. https://doi.org/10.1016/j.nepr.2017.09.004.

1 Brennan, Graeme, and Rob McSherry. “Exploring the Transition and Professional Socialisation from Health Care Assistant to Student Nurse.” Nurse Education in Practice 7, no. 4 (July 1, 2007): 206–14. https://doi.org/10.1016/j.nepr.2006.08.006. ↑

2 Lave, Jean, and Etienne Wenger. Situated Learning: Legitimate Peripheral Participation. Cambridge University Press, 1991. ↑

Featured image by Flikr user tmccnevada

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