Are we prepared to educate the next generation of bachelor nursing students? A discussion paper

Abstract

This paper answers a call from Nordic colleagues for new strategies in education to meet the needs of a new generation of bachelor nursing students regarding the development of clinical skills. We, as they, believe that educational models targeting the development of clinical skills must be customised to meet the learning style of the current and future generations of bachelor nursing students. In this paper we put forward that using a comprehensive, collaborative, student-centred approach will assist younger generations’ learning processes. We describe a pedagogical model of peer learning that combines collaboration, reflection and assessment aligned with learning outcomes. Such an approach, we believe, is likely to be in line with expectations, needs and preconditions of the current and future generations of nursing students.

Introduction

In a thought-provoking discussion paper – published here in the Nordic Journal of Nursing Research – Nordic colleagues ¹ call for new strategies in education to meet the needs of a new generation of bachelor nursing students regarding the development of clinical skills. They propose an Objective Structured Clinical Reflection (OSCR) tool based on or inspired by existing tools for clinical evaluation of students, such as the Objective Structured Clinical Exam (OSCE), Objective Structured Clinical Assessment (OSCA) or Assessment of Clinical Education (AssCE), as a solution. They deduce that a stronger emphasis on reflection would meet generations Y and Z’s need for clear expectations and answers, immediate individual feedback and formative and reflective assessment. Our Nordic colleagues’ call for action, regarding generation-customised teaching and assessment in clinical studies inspired us to reflect upon our own educational practices. Thus, in this paper we will describe how two Nordic Higher Educational Institutions (HEIs) – in Norway and Sweden – have applied teaching and learning activities that we suggest will be useful in meeting generations Y and Z’s learning styles, expectations, needs and preconditions. We will illustrate a pedagogical model for peer learning that includes collaboration, reflection and assessment aligned with learning outcomes, that prepare students for collaborative and active learning.

Generation-customised teaching strategies

A student's character traits influence his or her learning process. ² Some of these traits are not solely personal; they can also be seen as generalisations for whole generations. Intragenerational traits and intergenerational differences may affect what are considered to be effective teaching methods. ³ The majority of today's nursing students belong to generation Y, and the nursing faculty belong to generation X. Generational differences, such as preferred form of social interaction (digital vs. face-to-face), attention span (limited and immediate vs. persistent and deliberate) and digital competence (technologically savvy vs. less experienced), may create tension between the expectations of how teachers should teach and how students learn best. Generation Z is on our doorsteps, and members of this generation are digital natives, having been born into the world surrounded by technology. Thus, understanding intergenerational differences is vital for recruitment and for preventing attrition in a multigenerational workplace. ⁴ It is safe to assume that the same is true for building a successful teaching and learning environment in higher education. Generation X students, who are today's majority of the teachers in higher education, are described to prefer an individualistic and teacher-led approach. ⁵ Now, we believe, a more collaborative, student-centred approach that aligns with the principles of social constructivism ⁶ is needed to support the learning styles and preferences of the younger generations.

Challenges in teaching and learning clinical skills

Teaching and learning clinical skills during bachelor nursing education is a complex process, and the most effective teaching method depends on the purpose of the teaching activity, the content, the student, and the teacher. ⁷ The goal of all teaching activities in the education of nurses is obvious: to provide students with a set of clinical skills in accordance with expectations and requirements. Clinical skills are comprised of professional and personal qualities founded in internalised and up-to-date knowledge and competence and, as such, illustrate the complexity of nursing. This complexity complicates the student's process of learning clinical skills. Clinical skills are apparently practical and can unconsciously be perceived as instrumental tasks, such as giving injections or assisting the patient with personal hygiene. In reference to McMillan's term ‘the hidden curriculum’, ⁸ we are aware that some teachers and preceptors, most likely unintentionally, describe nursing skills and activities as routine practical tasks rather than as complex activities that combine evidence-based knowledge and clinical skills, including compassion and person-centred relational skills. It is not controversial to assume that such misperceptions of registered nurses’ clinical skills give rise to a mismatch between students’ expectations and experiences, commonly referred to as a theory–practice gap. As argued by our Nordic colleagues, ¹ reflection is a key to learn clinical skills and we may add bridging the theory–practice gap. ⁹

In their paper, Gunnarsdottir et al. ¹ emphasise the last stage of a learning process: evaluating the achievement of learning outcomes through structured reflection. ¹ Our focal point in this paper is the entire learning process, prior to and including the assessment of clinical skills where reflection is one of the elements. We do not consider our approach to be in opposition to our Nordic colleagues’ suggestion; ¹ we see both our suggestions as tools in the toolbox supporting teachers in teaching and students in learning clinical skills.

Comprehensive learning processes

Outcome-focused nursing education was implemented in Sweden more than a decade ago (2007) and only very recently in Norway (2020), and is evident in our two HEIs’ structure, content, and pedagogical methods. In 2011, Karlstad University in Sweden (KAU) introduced a curriculum that presented a shift from a focus on teaching to a focus on the students’ learning and learning outcome (knowledge, skills, competence). Professional clinical skills were the point of departure with the aim to contextualise knowledge by integrating subject matter, theory, and practice. ¹⁰ In Norway, new national guidelines introduced in 2019 required all HEIs educating nurses to redesign their curriculums from being input-oriented (regulated content) to being output-oriented (in which final qualifications are defined). At Lovisenberg Diaconal University College in Norway (LDUC) the curriculum's learning objectives demonstrate coherence and progression between courses and throughout the study programme, forming a structure that supports a comprehensive learning process. Comprehensive learning processes at KAU and LDUC connect on-campus theoretical study activities, clinical training and simulation with structured learning activities, peer learning and structured assessment (AssCE ¹¹ ) in clinical placements.

Peer learning

Peer learning is defined as learning through interactions between equals, i.e. students learn from each other by actively seeking knowledge, problematising and reflecting on different learning situations.^12,13 Stenberg and Carlson ¹⁴ argue that healthcare education must prepare students for collaborative learning by, for example, using peer learning as a pedagogical model. Because peer learning is based on interaction, collaboration, peer assessment and reflection, students can expand their knowledge, identify their and their peers’ strengths and weaknesses and develop personal and professional skills by evaluating each other’s professional competence. ¹³ In this way, students who share common learning experiences increase their confidence and understanding of the context. The fact that peer learning includes collaboration, peer assessment and reflection can be used strategically to enhance students’ engagement in their own learning in academic and clinical settings and to address the challenges presented by the learning style of future generations as described by our Nordic colleagues.

KAU introduced the pedagogical model of peer learning for the 2017–2018 school year to cater to larger student cohorts while maintaining quality clinical education and safe patient care. The foundation for the implementation of peer learning in clinical education was a supervision model used by KAU and the county council of Värmland since the turn of the millennium; details are presented in Olsson et al. ¹² As established at KAU and currently being implemented at LDUC, the group of students plan person-centred care in cooperation with their patients. Thereafter, the students bounce ideas between themselves, and before care is delivered, their preceptor is informed of the intended actions. The students are then expected to deepen their knowledge and reflective ability in clinical seminars led by university lecturers, where patients’ situations and the nursing students’ experiences are discussed. The students learn through hands-on experiences, reflection and group-based collaboration, a learning style associated with generation Y students. ¹⁵ This, combined with continuous supervision of planning and delivery of care, enables immediate feedback, maintaining the students’ attention. At both our HEIs, the nursing students undergo formative and summative assessments of their clinical competence and skills by using the assessment tool AssCE. A newly developed smartphone application for digital follow-up is currently being tested at LDUC. ¹⁶ For digitally savvy students, a digital and immediately available communication tool where the student, the teacher and the preceptor interact, reflect, and collaborate and that integrates the relevant learning outcomes and AssCE, is likely to be useful and welcomed by generations Y and Z. Although our two HEIs’ curriculums differ, both institutions have applied a comprehensive approach integrating theoretical and clinical issues, emphasising the students’ learning process through reflection and student–student, student–preceptor and student–teacher collaboration, and formative and summative assessment of clinical skills.

Conclusion and implications

Designing and applying educational models that support different generations’ learning processes is complex and challenging. We recognise Gunnarsdottir et al.'s ¹ emphasis on structured reflection as a strategy for assessing, yet also teaching and learning clinical nursing skills. However, reflection involves exploring clinical experiences through thoughts, feelings and beliefs, which, though important for professional development, make the reflection subjective. We propose that a comprehensive approach would be more effective than, but not excluding, a single objective assessment tool. Such an approach is based on learning outcomes and connects theoretical knowledge, on-campus training and simulation with in-practice structured learning activities, peer learning and formative and summative assessment. No matter what assessment instrument is used, it must be able to assess the students’ progression in clinical skills and ensure that their nursing competence is in line with the official requirements and professional expectations. Thus, student follow-up and assessments must be interlinked beyond the single period of a clinical placement. Finally, our Nordic colleagues’ ¹ suggestions and our reflections have demonstrated that there is a need for longitudinal research exploring different approaches and their suitability for current and future generations of nursing students.