Abstract
Nursing education in the Nordic countries follows the European Union directive requirements, and clinical studies for nursing students in the Nordic countries have many similarities. Now a new generation of students with different needs and characteristics is entering the nursing profession. The faculty, teachers and nurses will face challenges in meeting this new generation’s needs. The primary aim of this discussion paper is to explore and compare the current clinical studies in the five Nordic countries. The secondary aim is to find means to address the future challenges with a focus on the new generation. The idea of Objective Structured Clinical Reflection creates the possibility to discuss a new form of evaluation that may enhance the clinical competencies of the new generation entering clinical studies during their nursing education.
Keywords
Introduction
The Nordic countries – Denmark, Finland, Iceland, Norway and Sweden – have much in common in terms of their culture, social and political structure and healthcare and nursing education. This can be beneficial for cooperation and comparisons within the healthcare sector and healthcare education including nursing education. Cooperation and comparisons may drive and enhance development and harmonisation in theoretical and clinical studies. 1 All Nordic countries must adhere to the European Union Directions that regulate the theoretical and clinical aspects of nursing education. These are overriding common guidelines that must be followed, e.g. prescribed areas for clinical studies. The quality of clinical studies usually reflects the quality of curriculum structure, and these aspects have been discussed in relation to nursing students’ satisfaction. 2
Since clinical studies in a clinical environment form a significant part of the curriculum, the EU directives do not prescribe minimum pedagogical qualifications or experience for preceptors in the clinical environment. The quality of the preceptors’ supervision needs to be recognised. 3 Preceptorship has an impact on clinical competence and the nursing student’s readiness and satisfaction towards the profession.
There appears to be great difficulty in agreeing on a definition of the concept of clinical competence both in nursing and education, which creates a challenge for researchers. Therefore, in this discussion, clinical competence refers to skills, abstract knowledge and understanding and attitude, i.e. being adequately qualified and capable. It is important to avoid the synonymity of competence with performance; therefore, the integration of know-how and emotional readiness via dialogue and reflection becomes challenging. 4
Constant evaluation of the quality of the clinical education aspects of nursing education is important. Strong clinical education should always be an objective with the aim of supporting the students in developing and gaining adequate skills and knowledge and preparing them for a complicated, multifocal and constantly changing working environment. This is particularly the case when technology expands and the students are of a new generation. The students who are enrolling in nursing education in 2021 are from a mixture of generation Y and Z. This calls for new strategies in education both in the faculty and clinical environment. The generation born between 1985–2005 is known as the millennials or generation Y. This generation has been described as highly protected and overscheduled winners, and as perceiving themselves as special. 5 They prefer to work in groups with hands-on experience and place less value on reading and listening to lectures. 6 This generation likes to take part in organising their programme and to have an input in what they are studying. They also like to have a personal connection with faculty and staff members to have someone to turn to with questions and concerns. Youths born from around 1995–2012 are referred to as generation Z (sometimes referred to as the iGeneration/iGen or net Generation). 6 , 7 Their frequent interaction with the digital world may have put them at risk for being underdeveloped in social and relationship skills, making them at increased risk of isolation. They do not like repetition or monotony and have a limited attention span. However, they are also pragmatic and desire convenience and immediacy. Chicca and Shellenbarger, 7 state that if we do not change our traditional pedagogical approach, we will not meet these students’ needs.
This discussion paper presents a reflection with the primary aim of exploring and comparing the current clinical studies in the clinical environment in one nursing faculty from each of the five Nordic countries: Denmark, Finland, Iceland, Norway and Sweden. We initially explored and compared several overall variables for clinical studies in all five countries. These related to: the length of clinical education; the aim of each clinical study period; the objectives; the evaluation criteria; the frequency of meetings with the teaching staff from the faculty; the frequency of meetings with the clinical preceptors assigned in the clinical environment; who acts as clinical preceptor; how final assessment is conducted; and what the evaluation criteria are. The secondary aim is to address the future development needs and relates to the evaluation of nursing students in clinical studies.
Discussion
Clinical studies in the Nordic countries
Clinical studies are worth 90 European Credit Transfer System (ECTS) in all countries, but the length of each course varies. The bachelor nursing (BNS) qualification in Sweden and Norway comprises 180 ECTS, of which clinical studies comprise 50%; in Denmark and Finland it is 210 ECTS comprising 42.8% clinical studies; and in Iceland it is 240 ECTS comprising 37.5% clinical studies.
The way clinical studies are structured in the universities researched have some similarities. For example, the aim of clinical studies for all universities was related to learning outcomes and the specific content of the clinical study period. The students, together with the preceptor, set their own objectives for the clinical course to meet the aims. In all of the Nordic countries, each clinical course specifies what students should achieve. These objectives and learning outcomes are the evaluation criteria in clinical studies in all institutions in the different countries. The evaluation criteria relate to the goals of clinical studies and they outline the way the student can reach the goal by setting objectives at the beginning of the clinical period. The students plan how they will achieve the goal together with their preceptor from the clinical environment. The formulas used for assessment vary from open description of the student’s goals achievement to a more structured formula to check that the learning outcomes have been met.
Students in all the countries have a main preceptor who has the responsibility to guide the students during their clinical period. Likewise, all nurses on the wards can act as a preceptor in all countries. Thus, students in all countries may have between two to four preceptors in addition to their main preceptor. The nurses acting as preceptors mostly do not have special education in supervision, coaching or mentoring skills. All countries recommend that they do, but this is not compulsory. In Sweden, approximately 27% have additional pedagogical education. 8 In Denmark, the main preceptor must have completed a six-week diploma course in pedagogy. In other countries, directives were not found. However, having a nurse as a personal preceptor is likely to increase the student’s clinical competence across all competence areas, i.e. knowledge-cognitive, skills and attitude.
In all countries, both individual and group assignments occur during the clinical study period. Seminars are conducted in smaller groups either in the clinical field or at the faculty. Usually, seminars are completed one to three times during one clinical period. In all universities, written assignments are presented in the seminar, and discussion with the main clinical preceptor about the learning outcome is usually the evaluation for the clinical period. Individual clinical examination as the final assessment concerning clinical skills and communication with patients has been developed in two clinical courses in a Swedish university. 9 However, clear objective criteria for evaluating students’ clinical competencies related to the aims of the clinical study that may meet the needs of the new generations seem to be lacking in all faculties.
Meeting the needs of a new generation
It is highly important to foster a student-centred environment by listening to students, offering additional support, providing clear constructive feedback, setting well-planned assignments, facilitating the meeting of individual learning needs, being innovative and promoting student voice. 10 Görlich and Katznelson 11 identify three overall components of educational trust: (1) social security and recognition, (2) flexibility in structures and (3) progression in skills. They suggest that the concept of educational trust creates a shift in focus from the individual young person to the role and function of the education system in aiming to reach the target of more young people completing education.
To meet the new generation’s needs meaningfully, a form of evaluation that can enhance the student’s clinical competencies achieved during the clinical study period is essential. Several useful strategies have been outlined to guide teachers when teaching and instructing generation Y. Contextual teaching based on case presentations and hands-on teaching and group discussion is preferable. Having a role model is important, as is the student’s immediate feedback on their achievement. Self-reflection exercises are also recommended. A study on the satisfaction of generation Z in the clinical learning environment indicates that these students thrive on accuracy and cultivated atmospheres that are satisfying and enjoyable. The same study included some suggestions for clinical faculty members such as allowing students to work at their own pace in live settings and communicating to them on specific assignments with achievable goals. Clear expectations should be discussed and feedback given. Furthermore, a solid relationship in the clinical environment with a staff nurse is important. Thus, to meet the desirable needs of generations Y and Z in the clinical environment, faculty members, preceptors and nurses may need to cooperate.
Clinical evaluation plays an important role; if it is inadequate, the evaluation may become too subjective and lacking objective criteria for successful and unsuccessful performance. Effective evaluation can be achieved through reflection guided by trained preceptors. In this reflection, generation Y and Z students can develop a personal connection. The reflection can also act as a platform for asking questions and sharing concerns. On the one hand, reflection during clinical studying presents a real-life perspective within caring science education. On the other hand, the availability of reflection as an assessment tool with a structured criterion can offer individualised feedback and may strengthen the objectivity and reliability of assessment.
Pathway for development
To meet the needs of generations Y and Z, and at the same time enhance clinical competence, a new form of reflective assessment must be developed. This type of reflective and formative assessment should include criteria that may enhance competencies via dialogue in areas such as critical thinking, ethics, collaborative behaviour, learning and development, satisfaction with provided care etc. However, the way we develop this form of reflective assessment for clinical studies requires careful examination.
The idea of Objective Structured Clinical Reflection (OSCR) is inspired foremost by the Objective Structured Clinical Exam (OSCE) and motivated by the necessity to ensure suitable knowledge, skills and competencies relevant to quality care. 12 During the past two decades, the OSCE has established its status in the medical world as a major tool for evaluating medical students’ clinical competence. Nursing also started to take an interest in this tool, and many applications can be found both in undergraduate and graduate nursing education, where it has become a formative evaluation tool. 13 In the clinical field, the Objective Structured Clinical Assessment (OSCA) examination noticeably increases the opportunity to evaluate real interpersonal communications. The idea underlying the OSCA was to improve the processes of the OSCE, particularly its reliability and validity.
Evaluating nurses and particularly nursing students’ skills and clinical competencies is a challenging task that often has implications for both the curriculum and the quality of patient care. Consequently, evaluating the clinical competence of nursing students is significant and must be based on a reliable tool. The OSCE has been considered and tested pursuant to clear measurements of reliability, validity, acceptance and applicability. However, a concern with the validity and reliability of the OSCE for nursing has been widely discussed in several studies. 13 An example of a validated assessment tool is the Assessment of Clinical Education (AssCE). 14 This tool is used for systematic and continuous assessment to support a dialogue about each student’s individual development and for both formative and summative assessment. This type of assessment forms the basis of, and can be used as a complement to, course examinations. The AssCE tool was found to support and improve nursing students’ clinical learning when preceptors, lectures and nursing students focused on the student’s knowledge, skills and professional judgements in the assessment meetings. 15
Conclusion and implications
Clinical studies in the five Nordic countries are similar in structure and content, but none of the countries have specific methods to meet the new generations’ needs. Therefore, we strongly support the development of new methods for teaching and evaluating in which reflection takes place in a pragmatic way that minimises the risk of isolation that may be faced by the new generation of nursing students. 7 Developing OSCR may bring the act of reflection to the level of personal connection with faculty and clinical preceptors, giving students someone to turn to with questions and concerns. This type of structured reflection empowers dialogue and is designed to assist student growth and facilitate deep learning. Furthermore, the aim of clinical studies is to enhance the nursing student’s ability to make clinical judgements, which involves critical thinking and reasoning; both difficult to evaluate. Hence, nursing clinical competence is more than a learning outcome and clinical skills that are being assessed during clinical studies. Nursing students are also required to develop critical thinking, ethical decision-making and multi-professional collaboration, 12 all of which can be best achieved via reflection, for which a tool such as OSCR could be highly beneficial.
