Bachelor of nursing students’ experience of dialogue with nurse lecturers

About the authors: Adam Proverbs, RN, MN, is clinical placement lead – nursing, at Toi Ohomai Institute of Technology, Tauranga, New Zealand. His correspondence address is [email protected] Patricia McClunie-Trust, RN, PhD, is a principal academic staff member at the Centre for Health and Social Practice, Te Tari Hauora me Te Tari Tikanga-ā-Hapori, Waikato Institute of Technology, Hamilton.   This article was accepted for publication in August 2018.	ABSTRACT Aim: Learning in clinical environments is a key aspect of the bachelor of nursing (BN) pre-registration programme. This article reports the findings of research exploring third-year BN students’ experiences of dialogue with nurse lecturers during clinical practice placements. Background: Third-year BN students have limited situational and ready-to-hand knowledge of how to approach clinical situations and nurse lecturers have an important role in helping them acquire knowledge in clinical practice. This research explores student experiences of interactions and conversations with nurse lecturers in clinical practice to understand more about how learning is supported through this relationship. Methodology: The research used an interpretive approach informed by Heideggarian phenomenology. Exploring students’ interpretation of interactions with nurse lecturers enables a deeper understanding of the meaning of dialogue in supporting learning in clinical practice. A purposive sample comprised three third-year nursing students from two different schools of nursing in New Zealand. Findings: Dialogue with nurse lecturers provides a significant source of support for BN students, especially when faced with challenging situations in practice. “Being a learner” emerged as the central theme, with three sub-themes evident: “experiencing the unfamiliar”, “being good” in clinical environments, and “professional sense making”. Conclusions: Nurse lecturers enhance BN students’ learning by listening to their experiences and providing strategies to help them make sense of clinical situations. Lecturers encourage growth and enhance the reflective skills of students using ready-to-hand situational clinical knowledge. Nursing education providers who prepare nurse lecturers sufficiently will enhance students’ learning during clinical practice experiences.
KEYWORDS student nurse, nurse lecturer, practicum, phenomenology, clinical learning, reflection

INTRODUCTION

LEARNING IN CLINICAL ENVIRONMENTS is a key aspect of the three-year bachelor of nursing (BN) pre-registration programmes in New Zealand. This article reports the findings of research exploring third-year BN students’ experiences of dialogue with nurse lecturers during clinical practice placements. The research was conducted with third-year BN students from two schools of nursing in New Zealand. Research highlights the importance of the clinical preceptor’s role as teacher for the nursing student (Spence, Vallant, Roud & Aspinall, 2012; Haitana & Bland, 2011; Levett-Jones & Lathlean, 2009). However, research is limited on the role of nursing lecturers and their interaction with students during clinical practicum. As nurse lecturers are seen as “teachers”, or as providing guidance in clinical practice, this research explored how these teaching skills and support were experienced by students.

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BACKGROUND

Clinical placements, or work-integrated learning experiences, are a central element of educating students in bachelor of nursing (BN) pre-registration programmes (Levett-Jones, Reid-Searl & Bourgeois, (2018). BN programmes in New Zealand consist of both theoretical classroom-based and online learning, and clinically-based learning experiences (Spence et al, 2012). The Nursing Council of New Zealand ([NCNZ] 2012) stipulates that undergraduate nursing students are to gain a minimum of 1100 hours of clinical experience prior to registration as a nurse. The organisation of relevant and appropriate clinical placements for BN students is complex and multifaceted (Henderson, Forrester & Heel, 2006). Within the required minimum of clinical practice hours, students are expected to experience a variety of settings, including acute medical/surgical, community and primary care, continuing care, and mental health (NCNZ, 2014).

Learning opportunities are identified by nurse lecturers through dialogue with students during clinical placements. For the purpose of this study, nursing lecturers are defined as masters-prepared registered nurses (RNs), who are employed by a university or institute of technology to oversee and integrate the academic components of students’ clinically-based learning experiences (Henderson et al, 2006; Henderson & Trede, 2017). RN preceptors, employed by the service provider where the student is placed, also provide clinical supervision to oversee the delivery of patient care, in collaboration with the nurse lecturer. While BN students are responsible for their own learning during clinical experiences, guidance and support from nursing lecturers maximises learning opportunities. Exploring how students experience guidance through dialogue with lecturers assists in understanding how dialogue contributes to acquiring knowledge.

BN students have limited situational and “ready-to-hand” knowledge about how to manage clinical situations. Clinical learning experiences help students understand contextual factors that influence nursing care, and recognise patterns in client presentations (Nielsen, Noone, Voss & Mathews, 2013). BN students’ development of critical reflection skills depends on being taught what is important to pay attention to (Benner, Hughes & Sutphen, 2008).

Experiential learning emphasises the process of how knowledge is acquired through experience. Reflection and de-briefing, or sharing narratives (Diekelmann, 2001; Ironside, Brown & Wonder, 2017) from clinical practice, is a powerful way of building knowledge by giving meaning to clinical situations. Facilitating reflective conversation or dialogue, involves “learning together” (Diekelmann, 2001), in “walking a path” with students (Burnard, 2002). Dialogue in clinical practice involves interaction and communication between the student and lecturer. This dialogue is relational and purposeful, supporting the student’s learning through reflection on practice experiences. Understanding of how students experience this dialogue with lecturers, helps the educators appreciate how students experience this learning support during clinical practice experiences.

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LITERATURE REVIEW

Starting new clinical placements regularly throughout the BN programme can be challenging for students, due to the complexity of health-service settings. “Belongingness” is a term that embodies students’ feelings of effective socialisation into clinical environments (Borrott, Day, Sedgwick & Levett-Jones, 2016; Levitt-Jones, Lathlean, Higgins & McMillan, 2009; Levett-Jones et al, 2018). However, it is not uncommon for them to feel isolated and disorientated during clinical placements; students may feel apprehensive about entering a clinical setting where they feel exposed and alone (Paton, Martin, McClunie-Trust & Weir, 2004). McBrien (2006) also acknowledges the challenges for BN students entering unfamiliar clinical environments, where they need to overcome fears and anxieties that can undermine their potential for learning. Interpersonal relationships formed by students with staff RNs have an important influence on students’ sense of “belongingness”. Levitt-Jones et al (2009) also suggest that once students have confidence in the staff they work with, they can more ably focus on learning.

Brown, Herd, Humphries and Paton (2005) found that students’ sense of belonging was also enhanced through the presence of a nurse lecturer, whom students consider part of their “team”. Students place a high premium on support systems (Liljedahl, Björck, Kalén, Ponzer & Laksov, 2016), including the support available from nurse lecturers, particularly the lecturer’s physical presence when visiting the clinical practice site (Gibbons, Dempster & Moutray, 2007). Gibbons et al suggest that students’ perception of support is a critical factor in determining their stress levels, consequently influencing their ability to fully participate in learning during clinical practice. Nurse lecturers have an important role in nurturing reflection during clinical practice experiences, where students feel free to explore hunches and seek solutions to complex problems (Ireland, 2008). Reflection, in dialogue with nurse lecturers, improves learning in clinical practice, especially when students feel their voices are heard and experiences understood (McAllister, Tower & Walker, 2007; Ryan & McAllister, 2018). Opportunities for deeper learning are facilitated through guided reflection on practice (Vanderheide & Walkington, 2009), including exploring how students interpret and assign meaning to experiences (Twibell, Ryan & Hermiz, 2005).

BN students possess unique individual histories and experiences that nurse lecturers need to honour within the context of learning in clinical practice (Myrick & Tamlyn, 2007). Standing (2007) suggests that past life experiences inform nursing students’ approach to clinical reasoning. Nurse lecturers who listen and co-interpret stories of clinical practice with students, and appreciate the complexity of learning associated with this process, are then best able to shape how students interpret future situations (Diekelmann, 2001). McAllister et al (2007) also suggest that using a transformative learning approach, where students are able to question and challenge the status quo in relation to best practice, increases the value of the knowledge they acquire. Nurse lecturers can model creative and critical thinking skills, encouraging students’ enthusiasm for scrutinising issues during clinical practice.

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DESIGN AND METHODOLOGY

This research used an interpretive phenomenological approach, drawing on the philosophical influences of Martin Heidegger (1889-1976) and Max van Manen (1942- ). Heidegger (1962) saw interpretive phenomenology as a study of being in the world, suggesting that we are always somewhere, therefore always being. These ideas come from the ontological approach to philosophy – that we have prior knowledge that guides our actions or responses to all moments, whether these things have been experienced previously or not. Essentially, the way we understand events depends on our own historical knowledge. To attach meanings to specific experiences, the interpreter must consider ontological factors potentially influencing our unique understanding of such experiences. This suggests that the researcher has pre-existing assumptions about the subject under investigation (Heidegger, 1962). Different individuals can interpret similarly-experienced situations in different ways, depending on the meaning of the situation to those individuals. However, it is impossible to be detached as a researcher when interpreting other people’s experiences (Heidegger, 1962). Previous life experiences influence the meaning we place on new situations.

Phenomenology uses “an open approach” (Miller, Buys & Woodbridge, 2012) to elicit and explore participants’ personal experiences, including the meanings and beliefs created as they interpret these experiences. Phenomenology provides researchers with the opportunity to enter other people’s worlds, to interpret the meaning of their experiences, and to understand others’ perspectives. The participant is understood as the “knower”, and the researcher seeks to interpret unique experiences as lived by that participant (Streubert & Carpenter, 1999). Phenomenology pays attention to lived experiences, considering temporality, comportment and rationality as central elements of the participant’s lifeworld (Creswell, 2013). Through this process, “The researcher enables the participant to openly discuss the phenomenon and, with this, the researcher gains access to the experience while moving into the participant’s reality” (Paton et al, 2004, p178). Understanding how it is to “be-in-the-world” of the student in clinical practice enables a rich and insightful phenomenological interpretation of the meaning of BN students’ dialogue with nurse lecturers.

Ethics

Ethical approval to conduct the research was obtained from the Wintec human ethics research committee. Students were not recruited from the school of nursing where the researcher is based as a lecturer, in order to avoid potential dual relationships with BN student participants. Fictitious names were assigned to each participant to protect their identity.

Participants

The study used purposeful sampling to recruit three students in the third year of the BN programme from two schools of nursing in New Zealand. Criteria for selection included being a full-time student undertaking clinical experience in the third year of a BN programme. A further criterion was that participants had attended the same school of nursing throughout their BN programme and had been exposed to clinical placements where they were supported by nursing lecturers.

Data collection

Data was collected through face-to-face interviews with the participants. Each participant was interviewed for approximately 90 minutes, with follow-up phone calls and emails to clarify aspects of their stories and to gain consent to using specific information from the verbatim interview transcripts.

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DATA ANALYSIS

For phenomenologists, data analysis is a reflective process and involves being sensitive to the meaning of experience (Morse, 1994). The data analysis framework used in this research was derived from Diekelmann et al (1989), allowing for an interpretive process that enabled the researcher to synthesise descriptions and develop themes derived from the participants’ narratives about their clinical practice experiences (LoBiondo-Wood & Haber, 2006). This approach enables nurse researchers to elicit rich and meaningful data from their participants and allows for a collaborative approach to gaining a mutual understanding of experiences. The stages described below were adapted from Diekelmann et al (1989):

1) Reading all transcripts for an overall understanding of the participants’ experiences.
2) Preparing interpretive summaries of each interview, and clarifying these summaries with the participants.
3) Analysing selected extracts of transcribed text that have common themes among the interviews.
4) Resolving conflicts between interviewees and researcher about interpretation of the data through discussion and amendment of the transcription.
5) Identifying and justifying recurring themes that reflect common meanings between participants.
6) Identifying relationships emerging between the themes, including correlating factors.

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FINDINGS

‘Being a learner’

“Being a learner” encapsulates the overall theme or central meaning of students’ clinical practice experiences – it is the students’ ambition to learn during clinical placements. Sub-themes were identified as “experiencing the unfamiliar”, “being good” and “professional sense-making”. The theme “experiencing the unfamiliar” relates to BN students seeking a sense of safety with someone familiar to them. The second theme identifies students’ sensing the need to “be good” during clinical practice experiences and seeking guidance from lecturers to manage challenging situations. The third theme, “professional sense-making”, shows how students give value to the nurse lecturer’s input relating to professional and practical learning. This includes their reliance on lecturers to make sense of clinical practice and professional experiences.

‘Experiencing the unfamiliar’

Students feel a sense of being on their own in an unfamiliar clinical environment, where they do not always know how to respond to challenges. Dialogue with nurse lecturers gives students a lifeline, a sense of safety, in an environment that feels unknown and sometimes unsafe. The students felt safer when dialogue and support from nurse lecturers was provided. They described the availability of the nurse lecturer as making them feel safer, even if their support and guidance was not deemed immediately necessary. Here, Alice recounts her first clinical experience and the support received from nurse lecturers:

“They [nurse lecturers] knew the layout and the set-up and most of them knew the nursing managers and things like that, so we felt quite safeguarded. We felt safe, but it was still quite a challenging experience just to get in there [clinical practice] and get face-to-face with people.”

Relationships between nurse lecturers and staff RNs in the clinical placement settings are noticed by students, and this appears to contribute towards a feeling of safety. Seeing a positive professional relationship between lecturers and RNs promotes a sense of comfort for the students. This sense of being safe presented itself in various ways. When confronted with a challenging event, such as a death of a client, during her practicum, Jane said:

“I think I really appreciated the fact that someone [a nurse lecturer] was looking out for me, and it was just to highlight that you are part of the team and they [nurse lecturer and clinical preceptor] are there to support, and you are not on your own and dealing with that sort of situation, that was quite helpful.”

In terms of comportment, Jane reflected on her prior experience of being a health-care assistant as helping her deal with such challenging situations. Learning from past exposure to similar events helped her deal with these experiences. Students also appreciate being able to seek guidance from someone who already knows them. Assigning a new nurse lecturer to a clinical environment appears to add a new dimension of difficulty for the student, who feels they need to prove themselves not only to the clinical preceptor, but also to the new nurse lecturer. Alice noted:

“You kind of get a bond with a [nurse lecturer] and it’s good, and they go, and then you get a new one and you don’t know them, and it is quite disruptive. You get used to teaching styles from those different lecturers, and you get new ones coming in and you have to settle in all over again, like you’re first years all over again. I think that long-term relationship is really important.”

Alice found it was like starting over again when a new nurse lecturer was assigned to her. Starting over requires the student to invest in building another relationship when they are already feeling vulnerable in an unfamiliar context. Dialogue with the new nurse lecturer could be seen as less meaningful for the student, due to a lack of trust in the relationship. The participants described feeling a sense of being abandoned when their communication with nurse lecturers was limited. This seemed apparent when Rose recalled her clinical experience where support was initially not in place:

“In one placement, we had a mixed group of tutors, I don’t even think we had one for the first couple of weeks, so it was only the last two weeks we had someone come, which was not great.”

Rose appeared to need reassurance that she was learning the right skills, clearly stating a need to confide in someone who was a trusted, safe, go-to person. On the whole, a sense of abandonment and isolation appears to be experienced as the third year of the BN course progresses. While the participating students acknowledged the need for their independence to be fostered, they sensed support being withdrawn suddenly during clinical practice experiences in their third year. Jane recalled a challenging situation in her third year, and when she sought guidance from a nurse lecturer, felt it was not as forthcoming as previously.

“I just feel like anytime I could speak to them, and now, I’m really conscious that they are doing a referral for me to Nursing Council and for ACE [post-registration employment process], and if I rock the boat, because I have already had some support, I don’t want to look like I’m needy or I’m not competent, which is silly because you are supposed to get support if you are struggling.”

Jane’s student-world appeared consumed by factors other than learning. Demonstrating a competent persona took priority, mainly influenced by impending future employment prospects. With her need to obtain good references, the ability to ask for support was greatly reduced, and her hope of protecting any future employment aspirations compromised her usual safety strategy.

‘Being good’

The participants identified tensions between balancing tasks in the clinical environment and experiencing learning opportunities – being a “good worker” or being a “good learner”. Being seen by RNs as a good worker sometimes took precedence over being a learner, and this interfered with their learning focus. However, “being seen to be doing the work” appeared to help students feel accepted by the clinical staff. Rose reflected on the challenges she experienced in knowing which role to adopt:

“I think without a nurse lecturer there to help you, it’s a lot easier to fall in to the health-care assistant role and not learn nursing skills. So you would be going off to do the beds and helping to toilet patients, and I guess it is easier to take the easier way out.”

Engaging in dialogue with a nurse lecturer guides the learning focus for students, giving meaning to the “learner role”. Rose’s story implies a struggle to understand her role in the clinical environment, illuminating challenges to students’ perception of clinical experience as time to learn. Ongoing guidance through dialogue with a nurse lecturer enabled this student to share her world, meaning that frustrations and confusion over her role identity could be managed. Another student, Alice, recalled how sometimes she was immersed in practicum and had little time for dialogue with nurse lecturers.

“You didn’t mind if it was quick [the dialogue], cause it was like, ‘ah yeah, I’ve got to go back to this patient’. They [nurse lecturers] make you feel reassured and that you still need to focus on your practice, and be able to step back. It’s really strange as a student because I haven’t personally been able to give it a true rationale for what I’m doing and how I’m doing it . . . ”

Reflecting on this dialogue, the idea of “stepping back” may show how the nurse lecturer also recognises this challenge to a learning focus, attempting to encourage a student to experience practice rather than engaging in a work role. However, sometimes it appears the RNs in the clinical environment dictate the role of students according to their understanding of what constitutes learning experiences. Rose recalls an experience during practicum in a residential-care facility during her third year, with limited nurse lecturer support:

“Sometimes they have one or two nurses for like 40 residents, they can be really, really busy, and you want to get on-side with the team and feel like you are forming those bonds, because you can’t just be standing around doing nothing. If you are just doing basic health-care assistant things, you are still getting a benefit from it, I get that, and I guess the better relationship you have with the staff and the residents, they are more likely to let you do things, like, ‘ah, this person is trying really, really hard, I’ll let her help.’ ”

Seeking a balance between “being good” and “being a learner” is challenging for students, especially when there is no nurse lecturer to help guide this process. The loss of nurse lecturer dialogue meant that Rose had less opportunity to discuss her role conflict. Therefore, she adopted a strategy allowing herself to be part of the team, or even part of the workforce, knowing that it might have both positive and negative implications for her learning.

Students sometimes experienced a sense of powerlessness in certain situations, and dialogue with nurse lecturers had a major influence on their perceptions of these experiences. Feeling powerless was sometimes due to the student’s sense of not feeling welcome in the clinical environment, and sometimes a feeling of “being in the way”. Recounting her dialogue with a nurse lecturer, Alice took comfort in how the nurse lecturer helped her identify what she was experiencing:

“She [nurse lecturer] sat me down and, said to me, ‘You’ve done well so far not to walk out’, and . . . she just talked me through it, and said, ‘Look, this is a good chance for you to learn resilience because you will come across this sort of behaviour, it looks close to bullying’, and just taught me different ways of dealing with it and how to confront and stand up for myself as a professional, but also to seek support from senior clinical staff. I was feeling quite incompetent because of what had happened; she said, ‘It’s not you, don’t let them make you feel that way, don’t take it to heart’, it was quite horrible.”

For students, dealing with stressful workplace relationships can be a daunting prospect. The sense of powerlessness they feel decreases when someone familiar to them helps to interpret and mediate their feelings about challenging situations. The importance of the opportunity for dialogue with the nurse lecturer is demonstrated here, in helping the student make sense of a situation and to recognise unprofessional behaviour towards her. Alice also recognised the importance of understanding power relationships between herself and the clinical staff, and the importance of using the support systems available to her. Understanding that nurse lecturers recognise this sense of powerlessness allows students some degree of empowerment, knowing they are not alone when confronted with challenging workplace relationships during clinical placements.

Professional ‘sense-making’

Dialogue between students and nurse lecturers focuses on reflection and post-event analysis. This reflection is not always directed at clinical judgements, but sometimes addresses professionalism and work-based issues. Conversations with nurse lecturers help students make sense of interactions with clinical staff, including how to approach situations in a professional way. Jane reflected on how her knowledge of resilience had developed over the three years of the BN programme and identified how dialogue with nurse lecturers influenced this development:

“I actually think that talk about resilience taught me to stand my ground, be quite clear and firm with people when something is not quite right. Then that confrontation thing for me . . . yeah, it did help . . .”

Standing one’s own ground and developing confidence in challenging staff situations illuminates how knowledge is acquired through experience. For students, resilience appears to develop over the course of the three years of the BN programme, based on previous experiences of managing similar situations. Acquiring knowledge is more than physical, task-based nursing. Empowering students to self-manage situations that challenge them supports professional development and a sense of professional accountability.

Nurse lecturers do not work alongside students in the clinical environment – the focus of their dialogue with students is on helping them make sense of the situations they encounter, thus acquiring situational knowledge. Drawing on the students’ experiences, lecturers help them recognise conceptual patterns in the practice situations they encounter. This is apparent in experiences recounted by Alice, who described coming to understand why these strategies are used to support her acquiring knowledge:

“They have given us ideas and a lot of thoughts about why you are doing this, that basic question about why you are doing things this way, and you have to come up with a rationale, and that’s when they question you, ‘Is that rationale going to work? Is that rationale of whether it’s for the betterment of the person or because it’s easier for you?’ ”

This approach used by the nurse lecturer provides the opportunity for students to reflect, interpret and offer rationales for their actions. Developing practice knowledge through reflection and critical analysis becomes a central focus for the dialogue. A sense of the students developing as practitioners is apparent here, as they notice how they are developing clinical reasoning skills through dialogue. Students can find the amount of information they are exposed to during practicums overwhelming and this sense of being overwhelmed hinders learning. Nurse lecturers encourage students to “step back” during dialogue, which helps them make sense of clinical situations and recognise patterns in assessment data. Alice recounted an experience in an emergency department (ED):

“It [the dialogue] helped you step out of that moment. I got to a point where I would just freeze, because there was so much going on, you just couldn’t process it all. There would be things like pain, or UTIs [urinary tract infections], and how people act with delirium. So, you’ve got a patient who has come into ED acting ‘la’, and you get a urine sample and go and test it. That would be the kind of time where they [nurse lecturer] would give you little pointers because they have had the experience, and it would make the brain unfreeze . . . ”

Dialogue focused on reflection strategies helped Alice make sense of the responses that were required in this situation. Alice’s ability to consider all that was happening in this situation was limited due to having little practice experience. Dialogue about practice experiences helps students to own their learning and understand reflection as part of the process they need to engage in to develop their nursing knowledge and perform capably in practice.

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DISCUSSION

Nurse lecturers guide and support students’ socialisation into clinical environments, often using the lecturer’s own existing relationships and experience. Students appear to highly value the benefits that this interaction with and support from nurse lecturers brings to their learning (Croxon & Maginnis, 2009; Brown et al, 2005), including supporting their social integration into the clinical environment (Levett-Jones & Lathlean, 2007; Levett-Jones et al, 2018). Knowing nurse lecturers are in the background during clinical placements gives students a sense of safety and this feeling is fostered through various forms of communication. Access to a familiar face, someone who knows the student, provides a sense of security and safety, whether their input and guidance is required or not (Brown et al, 2005). As Ryan and McAllister (2018) suggest, students feel secure in knowing a nurse lecturer is accessible during clinical experiences, because of their expertise and familiarity.

Visits to individual students by nurse lecturers during clinical practice experiences, allows a process of scaffolding knowledge to occur with students. These visits also have the potential to enhance relationships between clinical preceptors and nurse lecturers (Liljedhahl et al, 2016). A sense of being part of the team supports students’ socialisation and learning. Paton et al (2004) identified how students observe nurse lecturers’ and clinical preceptors’ interaction, and a collaborative approach between them enhances students’ motivation to learn, and their sense of security. This collaboration reduces the student’s sense of being an outsider in the clinical environment. Levett-Jones et al (2018) propose that this perceived investment of interest in the student’s learning experience in the clinical environment enhances learning potential for the student. However, if students do not feel this support, learning opportunities may not be fully utilised (Borrott et al, 2016; Bradbury-Jones, Irvine & Sambrook, 2010).

The timing of dialogue during clinical placements was also identified by students as having an effect on their clinical experience, as was the ability of the education provider to facilitate nurse lecturer cover. Poorly-timed dialogue with the nurse lecturer, even when dialogue was requested, had a negative impact on clinical experiences. The dialogue with the nurse lecturer in the final year of the BN programme appears to be just as important as in the earlier years, given the increased complexity of situations students are required to interpret and respond to (Brown et al, 2005; O’Mara, McDonald, Gillespie, Brown & Miles, 2014). Preparing students to practice as RNs involves fostering independence and providing space for them to practise their new knowledge and skills to gain personal confidence (McAllister et al, 2007). However, in fostering independence, there is a balance that needs to be considered, to manage students’ anxiety.
Support through dialogue with nurse lecturers helps students develop resilience through negotiating stressful workplace relationships, enabling them to learn professional approaches to conflict resolution. Students are also reassured when they have the opportunity to discuss feelings of powerlessness (Bickoff, Levett-Jones & Sinclair, 2016; Courtney-Pratt, Pich, Levett-Jones & Moxey, 2018). Tensions between being required to learn during clinical placements, and being seen to “do the work” were felt acutely by students. When the work role takes dominance over learning, students feel more like health-care assistants, rather than learners (Brammer, 2008). Guidance from nurse lecturers helps students to develop clarity about their role in clinical settings and supports professional ways of asserting this in practice. However, Brown et al (2005) said that if students perceived no-one was guiding their clinical learning, they would potentially fall into a non-learning role. This is especially apparent in some clinical settings, particularly where there is a low RN-to-student ratio – this diminishes the learning value of the student’s clinical experience (Croxon & Maginnis, 2009). Lecturers’ mediation role is seen by students as enabling, giving them strategies to manage challenging situations. Best (2005) highlights how the perceived power difference between students and clinical nursing staff can create conflict.

Students appreciate the opportunity to use the lecturer as a reflective tool, to clarify their thought processes and reasoning skills. According to Bradbury-Jones et al, (2010) reflection and building problem-solving skills for increasingly complex situations enables students’ professional development through references to practical experience. This process, when guided expertly by lecturers, enhances experiential learning. Ongoing reflective dialogue can help to reveal and define clinical problems that sometimes may not be obvious to the lone reflector (Duffy, 2008). Brown et al (2005) highlight the role of lecturers in clinical practice as a “sounding board”. In this sense, the task of the lecturer is to nurture habits of the mind that cultivate reflection on practice (Ireland, 2008). Encouraging students to look more deeply into their clinical experiences facilitates the progression towards more critical thinking (Levett-Jones, 2013). As Levett-Jones suggests, questioning by lecturers during dialogue in practicum enables students to discover their own meaning of situations and develop their own understanding of nursing practice.

Health professionals use reflection to translate complex learning experiences into practice knowledge. Striking a balance between supporting students and enabling them to self-discover knowledge is sometimes difficult. Opportunities to reflect on situations and clarify thinking and reasoning are highly valued by students (Lowe, Rappolt, Jaglal & McDonald, 2007), emphasising the importance of dialogue with nurse lecturers. Having guidance enables students to formulate critical skills in nursing, by learning to notice what information is important, and what is not, in nursing situations. The lecturer uses their practice wisdom to help students learn by interpreting the context in which practice situations occur. Sometimes learning opportunities are not recognised by students until dialogue has taken place with the nurse lecturer.

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RECOMMENDATIONS

The central themes in these findings call attention to some important considerations for how clinical practice experiences are managed within complex and rapidly changing clinical environments. They also show how students’ ongoing need for support from nurse lecturers is required through the differing levels of BN programme to help them successfully navigate clinical learning experiences.

• Students doing clinical placements in their final year require lecturer support to help them reflect on complex clinical situations. Providers of nursing education need to clarify the focus and purpose of the nurse lecturer role during each year or stage of the BN programme.
• Close collaboration and relationships are needed between nursing education providers and clinical placement providers to enable maximum learning opportunities for BN students.
• Providers of nursing education need to be mindful that nurse lecturer continuity is important for students, providing them with a consistent familiar face in unfamiliar learning environments.
• Nurse lecturers need to teach students negotiating skills when they need them, including techniques for resolving conflicts, while also promoting students’ resilience, where they encounter stressful workplace relationships.
• Students appreciate nurse lecturers who help them use a reflective approach to making sense of clinical environments. Therefore, preparing lecturers to facilitate this process provides a safe learning partnership.

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LIMITATIONS

The findings presented in this research have been generated from a small sample size, therefore it may be assumed they do not fully represent the breadth of nursing students’ experiences of dialogue with nurse lecturers. While the three students’ narratives about their experiences provide a rich insight into the student world, and the ways in which they comport themselves within this world, the generalisability of these findings may be limited.

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CONCLUSIONS

The supportive aspect of dialogue between nurse lecturers and students is highly valued by students to help their learning. These findings suggest that dialogue is appreciated by students, even in the later stages of the BN programme. Student learning is centred on many aspects of nursing, ranging from clinical scenarios to professionalism within the workplace. In guiding and supporting student learning, nurse lecturers are a crucial tool for students, especially when they are seeking clarification about what they observe and experience during clinical practice.

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