https://www.infirmiere-canadienne.com/blogs/ic-contenu/2023/05/29/reduire-lanxiete-liee-a-la-pratique-clinique
How to acknowledge and eliminate barriers to effective learning
By Stephanie Won
May 29, 2023
istockphoto.com/izusek
When students feel that their relationship with their instructor is not harmonious, they can lose focus on the intended clinical practice outcomes while focusing on the internal stress created by the student-instructor relationship.
Takeaway messages
- Instructor-led clinical practice rotations provide nursing students with unique yet anxiety-provoking learning experiences.
- Students often spend a disproportionate amount of time worrying about the student-instructor relationship rather than the intended clinical practice learning outcomes. Preoccupation with thoughts of clinical failure can create performance anxiety, fear, distrust and frustration.
- When instructors use a strength-based approach, they help foster open communication, trust, and a reasonable working relationship with their student nurses. When a student perceives that their instructor is working with them toward success, their stress and anxiety decrease, therefore allowing them to focus on the intended learning.
Nursing students experience significantly elevated levels of stress and anxiety compared to other academic programs due to the unique nature of nursing education (Amattayakong et al., 2020; Turner & McCarthy, 2017). Unlike many other programs, nursing combines competitive entry requirements, a heavy academic workload, and simultaneous clinical practice experience throughout the academic year (Turner & McCarthy, 2017). The cumulative effect of these stressors, in addition to daily family, life, and work considerations, can lead to negative student outcomes and burnout before these novice nurses even enter the workforce.
When looking at the various stressors nursing students face, Amattayakong et al. (2020) noted high levels of reported stress related to the clinical practice environment. Nursing education programs in Canada require students to complete a substantial number of clinical practice hours before graduating (Garrett & MacPhee, 2014).
Although clinical practice hours in Canada are not nationally regulated, some countries with similar program structures, such as the United Kingdom, expect nursing students to spend 50 per cent of their academic time in clinical practice (Garrett & MacPhee, 2014). Nursing students reported that one of the most impactful aspects of their clinical practice experience is the working relationship formed with their instructor (Serçekuş & Başkale, 2016) and that general perceptions of instructor incivility can cause fear and anxiety (Brown et al., 2021). Conversely, students who perceive their student-instructor relationship to be supportive report having higher satisfaction in the clinical practice setting and positive academic outcomes (Chan et al., 2017).
When students feel that their relationship with their instructor is not harmonious, they can lose focus on the intended clinical practice outcomes while focusing on the internal stress created by the student-instructor relationship. It is key to explore what barriers students identify as hindering the development of a supportive student-instructor relationship and what supports are most effective at reducing student stress and anxiety (Turner & McCarthy, 2017).
Barriers
Identifying barriers to successful clinical practice relationships is an important step toward creating supportive student-instructor relationships. Mikkonen et al. (2015) noted that overarching factors such as course evaluation can have an impact when assessing student satisfaction. If students feel that an instructor’s evaluation processes are not fair or clearly explained, it can hinder the working relationship between student and instructor. If foundational aspects of clinical practice are not set out properly, the student-instructor relationship can be disadvantaged from the start.
Focusing on daily student-instructor interactions, students report that a lack of feedback or guidance within the clinical practice setting can establish feelings of an uncaring learning environment (Mikkonen et al., 2015). Likewise, the timing of feedback plays an important role in student-instructor relationships. Students report that the delivery of constructive or negative feedback in front of the patient can create feelings of frustration, performance anxiety, and fear that they may lose a sense of patient trust (Serçekuş & Başkale, 2016).
Questioning students about practical knowledge in the clinical setting prior to patient care is a common teaching practice. However, if not presented supportively, this approach can create feelings of pressure and a lack of instructor trust. Ultimately, this process increases student stress levels while feeling as though they are being quizzed (Amattayakong et al., 2020). When questioning students, instructors should tailor in-the-moment feedback and pre-skill questioning to their unique student group, ensuring that these strategies do not create barriers to healthy working relationships.
Serçekuş and Başkale (2016) noted that instructor inconsistencies can increase student stress and neglecting to explore the well-known gaps between theory and practice can leave students feeling disconnected from their classroom learning. Students also note that a barrier to a strong clinical practice relationship can occur when instructors hover too closely, therefore hindering a sense of freedom to explore and grow (Serçekuş & Başkale, 2016). Many of these outlined barriers, when examined through a solution-oriented lens, can present opportunities for support.
Supports
The student-instructor relationship includes an inherent power dynamic. Exploring and naming the power dynamic can help outline pre-existing expectations that the student and instructor may bring into clinical practice (Chan, Tong, & Henderson, 2017). Chan et al. (2017) noted that well-intentioned forms of “expert power” bring comfort, whereas notions of “coercive power” can damage a developing relationship (p. 111). Constructive use of expert power could be the instructor liaising with unit staff to ensure that there are mutually reasonable expectations for beginning learners and creating an environment for supportive learning (Cowen, Hubbard, & Hancock, 2016).
Instructor-facilitated exploration of the student’s fears and concerns, at the start of their clinical practice experience, can help foster trust and a sense of support. In addition to what the instructor is communicating, overall communication style is an outlined area of stress and anxiety for nursing students. Communication rooted in trust, support and empathy strengthens the student-instructor relationship, decreases overall clinical practice stress and increases motivation to learn and excel (Mikkonen, Kyngäs, & Kääriäinen, 2015; Serçekuş & Başkale, 2016). This type of communication fosters two-way dialogue in which students feel free to express areas of worry or a lack of understanding in a safe place (Mikkonen et al., 2015).
Challenges within the student-instructor relationship become acutely apparent when there are areas of practice that students may not be successfully developing. Instead of focusing initially and only on the areas that students do not understand or are not mastering, actively employing a strength-based approach can help empower students, instill hope, and foster self-efficacy toward clinical practice improvements (Brown et al., 2021).
When students perceive that their instructors are nice, positive and caring, it not only positively influences their personal experience but also increases their enthusiasm for learning and the development of caring practices within their patient care (Labrague, McEnroe-Petitte, Papathanasiou, Edet, & Arulappan, 2015; Serçekuş & Başkale, 2016).
Students report decreased clinical practice stress when evaluative standards seem reachable and when they feel a degree of autonomy in clinical practice to work toward these standards (Mikkonen et al., 2015).
Interestingly, the closeness of the relationship between student and instructor is a polarizing discussion in the current literature. Some students feel that developing a friendship with their instructor brings comfort and stress reduction. Other students firmly express the need for boundaries and that calling an instructor a friend would be inappropriate (Chan et al., 2017). As with all supports, creating a sense of balance within the student-instructor relationship facilitates open communication, a willingness to talk, and an overall reduction in student stress levels (Chan et al., 2017).
Conclusion
Exploring common barriers and embracing effective student supports can successfully reduce student-instructor-related stress and anxiety in the clinical practice setting. Instructors who mindfully employ a supportive approach with their students can help foster long-term benefits that students, faculty, future health-care employers, and patients will all benefit from (Turner & McCarthy, 2017). Being mindful of professional boundaries, clear evaluative competencies, and strong communication, a nursing instructor can assume the role of an educational ally to stand with students in the clinical practice setting. Moving beyond a power-over approach to nursing education and engaging in a power-beside approach will help free students to shift their focus from the stressful student-instructor dynamic to the more important patient care experience.
References
Amattayakong, C., Klunklin, A., Kunawiktikul, W., Kuntaruksa, K., & Turale, S. (2020). Wellness among nursing students: A qualitative study. Nurse Education in Practice, 48, 102867. doi:10.1016/j.nepr.2020.102867
Brown, J., McDonald, M., Besse, C., Manson, P., McDonald, R., Rohatinsky, N., & Singh, M. (2021). Nursing students’ academic success factors: A quantitative cross-sectional study. Nurse Educator, 46(2), E23–E27. doi:10.1097/NNE.0000000000000882
Chan, Z. C. Y., Tong, C. W., & Henderson, S. (2017). Uncovering nursing students’ views of their relationship with educators in a university context: A descriptive qualitative study. Nurse Education Today, 49, 110–114. doi:10.1016/j.nedt.2016.11.020
Cowen, K. J., Hubbard, L. J., & Hancock, D. C. (2016). Concerns of nursing students beginning clinical courses: A descriptive study. Nurse Education Today, 43, 64–68. doi:10.1016/j.nedt.2016.05.001
Garrett, B. M., & MacPhee, M. (2014). The slippery slope of nursing regulation: Challenging issues for contemporary nursing practice in Canada. Nursing Leadership, 27(3), 51–69. https://doi.org/10.12927/cjnl.2015.24057
Labrague, L. J., McEnroe-Petitte, D. M., Papathanasiou, I. V., Edet, O. B., & Arulappan, J. (2015). Impact of instructors’ caring on students’ perceptions of their own caring behaviors. Journal of Nursing Scholarship, 47(4), 338–346. doi:10.1111/jnu.12139
Mikkonen, K., Kyngäs, H., & Kääriäinen, M. (2015). Nursing students’ experiences of the empathy of their teachers: A qualitative study. Advances in Health Sciences Education, 20(3), 669–682. doi:10.1007/s10459-014-9554-0
Serçekuş, P., & Başkale, H. (2016). Nursing students’ perceptions about clinical learning environment in Turkey. Nurse Education in Practice, 17, 134–138. doi:10.1016/j.nepr.2015.12.008
Turner, K., & McCarthy, V. L. (2017). Stress and anxiety among nursing students: A review of intervention strategies in literature between 2009 and 2015. Nurse Education in Practice, 22, 21–29. doi:10.1016/j.nepr.2016.11.002
Stephanie Won, ID, MN, RN, is a nurse educator and program leader at Camosun College in the baccalaureate of science in nursing program, Victoria, BC.
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