Nursing student's final assessment in clinical practice : perceptions of teachers, students and mentors

(1)

(2)

Nursing students’ final assessment in clinical practice.

Perceptions of teachers, students and

mentors

(3)

(4)

KRISTIINA HELMINEN

Nursing students’ final assessment in clinical practice.

Perceptions of teachers, students and mentors

To be presented by permission of the Faculty of Health Sciences, University of Eastern Finland for public examination in Medistudia, Auditorium MS301, Kuopio,

on Friday, February 3^rd 2017, at 12 noon

Publications of the University of Eastern Finland Dissertations in Health Sciences

Number 403

Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland

Kuopio 2017

(5)

Lappeenranta, 2017 Series Editors:

Professor Tomi Laitinen, M.D., Ph.D.

Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences

Professor Hannele Turunen, Ph.D.

Department of Nursing Science Faculty of Health Sciences Professor Kai Kaarniranta, M.D., Ph.D.

Institute of Clinical Medicine, Ophthalmology Faculty of Health Sciences

Associate Professor (Tenure Track) Tarja Malm, Ph.D.

A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences

Lecturer Veli-Pekka Ranta, Ph.D. (pharmacy) School of Pharmacy

Faculty of Health Sciences Distributor:

University of Eastern Finland Kuopio Campus Library

P.O.Box 1627 FI-70211 Kuopio, Finland http://www.uef.fi/kirjasto ISBN (print): 978-952-61-2419-3

ISBN (pdf): 978-952-61-2420-9 ISSN (print): 1798-5706

ISSN (pdf): 1798-5714 ISSN-L: 1798-5706

(6)

III

Author’s address: Department of Nursing Science University of Eastern Finland KUOPIO

FINLAND

Supervisors: Professor Kerttu Tossavainen, Ph.D.

Department of Nursing Science University of Eastern Finland KUOPIO

FINLAND

Professor Hannele Turunen, Ph.D.

Department of Nursing Science University of Eastern Finland KUOPIO

FINLAND

Reviewers: Professor Maria Kääriäinen, Ph.D.

Department of Nursing Science and Health Management University of Oulu

OULU FINLAND

Professor Gary Rolfe, Ph.D.

Department of Human and Health Sciences University of Swansea

SWANSEA

UNITED KINGDOM

Opponent: Docent Leena Salminen, Ph.D.

Department of Nursing Science University of Turku

TURKU FINLAND

(7)

(8)

V Helminen, Kristiina

Nursing students’ final assessment in clinical practice. Perceptions of teachers, students and mentors.

University of Eastern Finland, Faculty of Health Sciences

Publications of the University of Eastern Finland. Dissertations in Health Sciences 403. 2017. 59 p.

ISBN (print): 978-952-61-2419-3 ISBN (pdf): 978-952-61-2420-9 ISSN (print): 1798-5706 ISSN (pdf): 1798-5714 ISSN-L: 1798-5706

ABSTRACT

The purpose of this study was to describe the views on the final assessment of nursing students in clinical practice. This topic is discussed particularly from the perspectives of nursing teachers, nursing students and mentors. The study investigated respondents’ views on using a standardized national or European scheme for clinical assessment. The study design included comparing similarities and differences in perceptions related to the concept of ‘final assessment’, aiming to explain the characteristics of the phenomenon of assessing nursing students’ clinical practice. There is a need for clarification to increase knowledge and mutual understanding of final assessment in clinical education, and studying this topic is therefore important.

The study was carried out in two phases. In the first phase, a literature review (years 2000–

2014) was carried out to provide an overview of the currently used approaches to final assessment of nursing students’ clinical practice. In the second phase, the questionnaire used in this study was designed. The study population included nursing teachers (n = 108) and nursing students (n = 276) in five Finnish universities of applied sciences and mentors (n = 225) in five partner hospitals. The data were collected between February and December of 2012. Response rates were 73 % for nursing teachers, 84 % for students, and 79 % for mentors.

As a result of the inductive content analysis of the narrative literature review (n = 23), three themes of final assessment were formed: ‘Acts performed before final assessment of student nurse clinical practice’, ‘The actual final assessment situation’ and ‘Acts after the assessment situation’. The role of the teacher and mentors was to ensure appropriate conditions for nursing students to improve their actions in nursing. Nursing students had the responsibility to act as active learners and to seek conditions that enable them to meet the qualifications to finally graduate as registered nurses. Based on the review, the assessment process is open to the subjective bias and the quality of assessment varies greatly. The survey data were analysed with descriptive statistics, cross-tabulations and exploratory factor analysis. The results of the survey data analysis showed that students had good abilities of self-assessment and they are treated equally in the final assessment situation. Furthermore, teachers, students and mentors all evaluated that mentors had enough time for mentoring the students and were therefore able to assess student performance at a sufficient level. The presence of the nursing teacher was highlighted also at the beginning of the clinical practice period, during the clinical placement and especially in the final assessment situation. In addition, an impression of mentor education was demonstrated in this study.

There is a need for common national standards for mentoring and assessment of clinical practice of nursing students to ensure that the criteria of nursing education are met and the competence of graduated registered nurses is guaranteed.

National Library of Medicine Classification: W Y 18

Medical Subject Headings: Education, Nursing; Students, Nursing; Mentors; Clinical Competence

(9)

(10)

VII

Helminen, Kristiina

Sairaanhoitajaopiskelijan ammattitaitoa edistävän harjoittelun loppuarviointi: Opettajien, opiskelijoiden ja ohjaajien näkemyksiä.

Itä-Suomen yliopisto, terveystieteiden tiedekunta

Publications of the University of Eastern Finland. Dissertations in Health Sciences 403. 2017. 59 s.

ISBN (print): 978-952-61-2419-3 ISBN (pdf): 978-952-61-2420-9 ISSN (print): 1798-5706 ISSN (pdf): 1798-5714 ISSN-L: 1798-5706

TIIVISTELMÄ

Tämän tutkimuksen tarkoituksena oli kuvata käsityksiä sairaanhoitajaopiskelijan ammattitaitoa edistävän harjoittelun loppuarvioinnista. Aihetta käsitellään erityisesti juuri hoitotyön opettajien, sairaanhoitajaopiskelijoiden ja työelämän ohjaajien näkökulmasta.

Tutkimuksessa selvitettiin myös vastaajien näkemyksiä tarpeesta yhdenmukaistaa kansallisesti tai Euroopan laajuisesti harjoittelun loppuarviointia. Lisäksi vertailtiin samankaltaisia ja erilaisia käsityksistä loppuarvioinnista tarkoituksena kuvata loppuarvioinnin ilmiötä.

Tutkimus toteutettiin kahdessa vaiheessa. Ensimmäisessä vaiheessa tehtiin kirjallisuuskatsaus (vuosilta 2000–2014), jonka tarkoituksena oli luoda katsaus sairaanhoitajaopiskelijan harjoittelun loppuarvioinnista. Toisessa vaiheessa aineisto kerättiin tätä tutkimusta varten laaditulla kyselylomakkeella hoitotyön opettajilta (n = 108) ja sairaanhoitajaopiskelijoilta (n = 276) viidestä ammattikorkeakoulusta ja työelämän ohjaajilta (n = 225) viidestä sairaalasta vuonna 2012. Opettajien osalta vastausprosentti oli 73 %, opiskelijoiden 84 % ja työelämän ohjaajien 79 %.

Kuvailevan kirjallisuuskatsauksen induktiivisen sisällönanalyysin (n = 23) tuloksena muodostettiin kolme teemaa: ‘Toiminta ennen sairaanhoitajaopiskelijan ammattitaitoa edistävän harjoittelun loppuarviointia’, ’Varsinainen loppuarviointitilanne’ ja ’Toiminta loppuarvioinnin jälkeen’. Hoitotyön opettajien ja työelämän ohjaajien tehtävänä oli varmistaa sairaanhoitajaopiskelijoille asianmukaiset mahdollisuudet kehittää hoitotyön osaamistaan. Sairaanhoitajaopiskelijoilla oli vastuu toimia aktiivisina oppijoina ja myös vastuu hakeutua tilanteisiin, joissa he voivat oppia riittävää osaamista valmistuakseen sairaanhoitajan ammattiin. Kirjallisuuskatsauksen perusteella arviointiprosessiin vaikuttivat henkilökohtaiset asenteet ja arvioinnin laatu vaihteli paljon.

Survey-tutkimus analysoitiin tilastollisilla tunnusluvuilla, ristiintaulukoinnilla ja eksploratiivisella faktorianalyysilla. Tämän survey-tutkimuksen tulokset osoittivat, että sairaanhoitajaopiskelijoilla oli hyvät itsearviointitaidot ja heitä kohdeltiin tasavertaisesti loppuarviointitilanteessa. Lisäksi opettajat, opiskelijat ja ohjaajat olivat sitä mieltä, että työelämän ohjaajilla oli riittävästi aikaa opiskelijan ohjaamiseen ja siksi heillä oli riittävät mahdollisuudet arvioida opiskelijoita asianmukaisesti. Hoitotyön opettajan läsnäoloa pidettiin tärkeänä sekä harjoittelun alkuvaiheessa, harjoittelujakson kuluessa että erityisesti loppuarviointitilanteessa. Tulosten perusteella työelämän ohjaajakoulutuksella oli merkitystä.

Tutkimus osoitti, että tarvitaan yhdenmukaisia normeja sairaanhoitajaopiskelijan ohjaamiseen ja arviointiin, jotta voidaan varmistaa vaadittu osaaminen opiskelijan valmistuessa sairaanhoitajaksi.

Luokitus: W Y 18

Yleinen suomalainen asiasanasto: opiskelijat; sairaanhoito; hoitoala; harjoittelu; arviointi

(11)

(12)

IX

Acknowledgements

I would like to owe my sincere gratitude to all those people who enabled my study and supported me during this process. Even though I do not personally acknowledge all of you here, this dissertation could not have been possible without your help. This study was carried out at the Department of Nursing Science of the University of Eastern Finland. The study focuses on nursing education, more specifically the final assessment of the clinical practice of nursing students from the perspectives of nursing teachers, nursing students and mentors.

I express my deepest acknowledgements to my principal supervisor, Professor Kerttu Tossavainen, PhD, for her scientific expertise, guidance and supportive comments throughout the course of the study. I am also very grateful to my second supervisor, Professor Hannele Turunen, PhD, for her valuable advice throughout my dissertation. The positive encouragement I received when working towards my aim was imperative for my study.

I am deeply thankful to the organisations and contact persons, and all the teachers, mentors and nursing students who participated in this study. Your involvement in the purposes of this study was indispensable, and our encounters were warm and memorable. I am privileged that you shared your views related to my research topic with me.

I warmly express my gratitude to Professor Maria Kääriäinen, PhD, and Professor Gary Rolfe, PhD, for their valuable, constructive and encouraging comments, which improved my thesis. I also want to thank Docent Leena Salminen, PhD, for accepting the request to act as my opponent.

I own my deepest respect to Professor Martin Johnson for his great help with the articles and for his genuine, intellectual support through these years. Your support was so essential and helped me in so many ways. I also own my sincere thanks MA Hannu Isoaho, MA, for his help with my statistical analyses Elisa Wulff, MA, for revising the English text and information specialist Maarit Putous for guiding me in the literature research.

This study was financially supported by the Finnish Foundation of Nursing Education and I express my gratitude for their support. I would also like to express my sincere thanks to the William and Ester Otsakorpi Foundation for their financial support, particularly Professor Kai Myrberg and Executive Director Mari Kurkan for having faith in my capability for completing this dissertation. Your emotional support was imperative for this process and you always made me feel appreciated.

I would also like to thank my working organisation, Saimaa University of Applied Sciences, in particular Rector Anneli Pirttilä as well as my superiors, Anne Suikkanen and Pirjo Huovila, for enabling my work arrangements and appreciating my efforts for completing doctoral studies through these years. I warmly thank all my colleagues, especially Pirjo Vaittinen, Päivi Löfman, Helena Wright, Susanna Tella and Tiina Väänänen for sharing an interest in my study process and providing me with encouraging comments. I owe my deep regards to my dear colleague Vuokko Koiranen, you have been my bridge over troubled water.

Kirsi Coco, I thank you for being my dear friend and a wise mentor as a senior researcher.

Those moments we have shared together and Carmelo’s delicious meals were so empowering. I would also like to express my thanks to my researcher colleague Minna-Maria Behm for sharing the journey of my thesis and encouraging me through these years.

My special thanks go to my close friends, Anne Korhonen, Leena Metso and Soile Paajanen:

thank you for our valuable encounters, our friendships have been very meaningful for me to survive through all these challenges of life. I could always trust your support whenever I needed it and feel safe whenever we are sharing our reflections together.

(13)

I owe my deepest gratitude for my late father, Taisto Peltola, who always had trust in my capability and led the way to adult learning. He always highlighted the importance of wide- ranging knowledge for me. I would like to warmly thank my mother, Ellen Peltola, for providing me with support in my everyday life; all those arrangements to meet my own and my family’s needs to enable my thesis process. My dear sister, Tanja Peltola, and my dear brother, Joni Leppikangas, and Joni’s children, Nelli and Joona, I would thank you for your love and unwavering support during all these years. You are so important to me.

Most of all, my loving thanks belong to my daughter Laura and my son Antti. Your understanding love and patience enabled me to complete this study process. You have always been the most important part of my life. My beloved husband Jouni, your love and positive attitude towards my efforts carried my thesis forward. Even in the moments when I did not believe in myself, you trusted my ability and encouraged me to work towards my goal. Thank you for all these years together.

In Ruokolahti, January 2017 Kristiina Helminen

(14)

XI

List of the original publications

This dissertation is based on the following original publications:

I Helminen K, Coco K, Johnson M, Turunen H and Tossavainen K. Summative assessment of clinical practice of student nurses: A review of the literature.

International Journal of Nursing Studies 53(1): 308-319, 2016.

II Helminen K, Tossavainen K and Turunen H. Assessing clinical practice of student nurses: Views of teachers, mentors and students. Nurse Education Today 34(8): 1161-1166, 2014.

III Helminen K, Tossavainen K, Turunen H and Johnson M. The experience of mentors in assessing the practice of undergraduate nursing students.

(Resubmitted 25.9.2016.)

IV Helminen K, Johnson M, Isoaho H, Turunen H and Tossavainen K. Final assessment of nursing students in clinical practice: Perspectives of nursing teachers, students and mentors in Finland. (Resubmitted 16.12.2016.)

The publications were adapted with the permission of the copyright owners.

(15)

(16)

XIII

Abbreviations

AACN American Association of Colleges of Nursing

ARENE Rectors' Conference of Finnish Universities of Applied Sciences ECTS European Credit Transfer and Accumulation System

EC European Commission

EU European Union

SOTE Sosiaali- ja terveydenhuollon palvelurakenneuudistus Health, social services and regional government reform NMC Nursing and Midwifery Council

UK United Kingdom

US United States

(19)

(20)

1 Introduction

This study focused on the implementation of the final assessment of the clinical practice of nursing students. In the recent ten years, there have been diverse demands for improving social and health care practices. At the moment, the most important reform of national services in Finland (Health, social services and regional government reform, or SOTE reform in brief) also challenges the perspective of professionals working in health care (Ministry of Social Affairs and Health 2016). To meet the growing requirements of social and health care, we need to ensure that the staff involved in these demanding professional circumstances is qualified and competent.

Higher education aims to ensure that graduates have extensive knowledge, skills and attitudes needed in working in specialist circumstances in their field. The aim of nursing education is to educate registered nurses who meet the needs of future health care; competent in nursing diagnosis and interventions, and meet standards of quality and safety in patient care (Ministry of Social Affairs and Health 2012, Willis Commission 2012). In Finland, the research of nursing students’ clinical practice has been traditionally a focus of nursing science, for example Eriksson (1981) and Hentinen (1989). Therefore, the scientific focus of this study is in the field of nursing science, especially nursing education.

In Finland, registered nurses are educated in the universities of applied sciences. Nursing teachers and mentors are required to ensure that nursing students acquire the ability to build up their skills of evidence-based nursing in clinical situations (Ministry of Social Affairs and Health 2003). However, for example Salminen et al. (2010) have argued that one of the future challenges in nursing education is nursing students’ learning and assessment process in clinical situations.

In Finland, university-educated teachers also have the responsibility for guiding and evaluating students in clinical practice (Ministry of Education 2006). ARENE, the Rectors' Conference of Finnish Universities of Applied Sciences, has expressed its concern over the financial cuts to educational institutes (Arene 2016). In recent years, there have been challenges related to improving and renewing functions with the available resources. Thus, this has also affected nursing education in the context of determining how to ensure the ability of nursing teachers to facilitate high quality assessment processes of the clinical practice of nursing students.

In recent years, nursing education has been subject to harmonizing measures of the European Union (2013). The aim of the measures has been to ensure that qualified registered nurses can work in any EU country under certain conditions. At the EU level, the studies of nursing students comprise clinical practice amounting to at least 50% of the extent of the degree. At the EU level, directives regulate that registered nurse education should take at least three years and contain at least 4,600 hours (180 ECTS) of education (EU 2013). Finnish registered nursing education contains 30 ECTS more, amounting to 210 ECTS and includes at least 90 ECTS (50% of the total 180 ECTS), or 2,300 hours, of clinical practice. In Finland, a Bachelor’s thesis of 15 ECTS accompanies these clinical practice studies. Therefore, it can be argued that nursing students

(21)

spend variable amounts, around 50%, of their studies in clinical practice with mentors assigned to them. Mentoring involves facilitating students’ learning in clinical placements and strengthening students’ professionalism (Bailey & Tuohy 2009, Jokelainen et al. 2011a). It is important for nursing students to be provided with feedback for their skills in order to understand needs for improvement in their clinical behavior (Heffernan et al. 2009, Bruno &

Santos 2010, Edmonds 2013, Xie et al. 2013). Nursing students must be able to improve their practice by appropriate assessment; therefore, proper scientific knowledge is needed to enable developing good models for assessment processes.

The purpose of assessment is to describe nursing students’ ability to perform the required tasks based on the relevant job description, that is, their ‘fitness to practice.’ It is significant to determine what is going to be assessed; the format of assessment affects students’ ways of studying, their interests in and focus of learning on the aims that are going to be assessed in clinical situations (Tiwari et al. 2005, Fong Leung et al. 2008, Al Kadri et al. 2009, Joughin 2010).

Previous studies on the topic of the assessment of nursing students have dealt with the matter from different perspectives, for example general clinical practice and feedback during the clinical practice period instead of the final clinical assessment. For example, Yanhua & Watson (2011) investigated trends in the evaluation of the clinical competence of nursing students, such as instrument development and approaches to testing competence. Mentoring and the student- mentor relationship have also been topics of interest in previous studies (e.g. Wilkes 2006, Jokelainen et al. 2011b, Henderson et al. 2012). The importance of comparing the perspectives of students, teachers and mentors has been identified (e.g. Bradshaw et al. 2012, Cassidy et al. 2012) and there is a need for further clarification in order to increase new knowledge and equal understanding of final assessment in clinical education. Even as the societal situation has changed, studying the topic continues to be of great importance.

This study is concerned with the final assessment of nursing students in clinical practice. In addition, the study describes and compares the views of nursing teachers, nursing students and mentors. This doctoral thesis comprises the main findings and summaries of four original articles and provides through these findings a conceptual framework of final assessment of nursing students in clinical practice. The study consists of two sub-studies: a review of the literature and a survey conducted among Finnish nursing teachers, nursing students and mentors. The aim is to produce information for nursing teachers, nursing students and mentors about the phenomenon of final assessment.

(22)

3

2 Final assessment in nursing students’ clinical practice

2.1 EDUCATIONAL THEORIES IN CLINICAL LEARNING

In nursing education, the learning environment has an important position for learning processes.

In order to ensure that nursing staff has the required competence to care for patients, there is a need for high quality strategies for the final assessment of nursing students’ clinical practice. In order to be successful, a learning process must include support from nursing teachers, relevant skills, prior experiential learning and required theoretical knowledge (Borneuf 2010, Sundler et al. 2014, Taylor et al. 2015). Social anthropologists Lave et al. found in 1984 that the active role of the context of learning highly impacts shaping the human cognition, and in 1989, Brown and colleagues formulated the term situated learning to portray the situation where the learning of a student takes place in certain enabling contexts. The teacher is not the owner of the knowledge and learning when the students are able to orientate their perspectives and work towards the needs in the context. (Korthagen 2010, Huang et al. 2011.)

The teachers’ and mentors’ conception of learning is essential in giving feedback to nursing students. Behaviorism has been the previously prevalent conception of learning. The essence of behaviorism is to see learning as consisting of step-by-step learning tasks proceeding from the simplest to the most difficult ones. Teachers are considered responsible for learning and exact models of how to act are used. Some teachers believe that this is effective at least in the initial stage of learning simple tasks. In contrast, cognitive development describes individuals’

learning/thinking strategies to information processing for learning and memorizing things. The student transforms incoming information into previous knowledge and applies this knowledge later to the environment. (Johnson & Johnson 1994, Quinn & Hughes 2007, Kwan & Wong 2015.) Constructivism is based on the idea that new knowledge is built upon and within the context of previous learning and highlights the active role of the student and their personal cognitive strategies and knowledge, and therefore new knowledge or abilities acquired differ between individuals (Guey et al. 2010). Sorin’s (2015) study suggested that there is a difference between the inner system of the one who learns and the external environment, e.g. community and culture, at which the learner refers to subjectively. In turn, the Vygotski’s model of socio-constructivism as a learning approach highlights the influence of social and interaction processes to our behavior.

For example, the ability to conduct critical thinking is considered imperative in the constructivist learning environment whereas the ability to reflect on the values and other factors which influence one’s own behavior is deemed meaningful (Kwan & Wong 2015). At the moment, constructivism and socio-constructivism as learning approaches can be seen emphasizing the active role of the nursing student as a learner in the nursing education curriculum (e.g. Saimaa

(23)

University of Applied Sciences 2016). The learning approach of teachers and mentors is imperative for the student assessment process.

2.1.1 Definition of concepts

Essentially, evaluation is concerned with the macro spectrum, e.g. documentation of programs, whereas assessment covers the micro spectrum, i.e. the assignment and assessment of smaller units of student work (Taras 2005, Hand 2006, Quinn & Hughes 2007, Cotter et al. 2009). Assessment provides a direction for learning for the student. It could be argued that assessment is commonly

‘for the student and teacher’ in the act of learning while evaluation is usually ‘for others’.

Formative assessment is an ongoing process and lasts throughout clinical education based on mentors giving feedback; its purpose is to advise the student towards a goal. Formative assessment prepares students for the summative assessment, which is usually undertaken at the end of education modules, and if students are unsuccessful, this may lead to the termination of the clinical practice period (Wallace 2003, Duers & Brown 2009, Jenkins 2010). It could also be described that formative assessment is ‘for’ learning and summative assessment is ‘of’ learning (Harlen 2005, Heron 2011). The term final assessment can be used both at the end of every nursing student’s clinical practice period and at the end of the study program before graduation (NMC, 2008). In this study, the term ‘final assessment’ is used to represent the assessment of nursing students’ clinical performance at the end of each clinical practice period in the same meaning as

‘summative assessment’. (See Figure 1).

Competence-based assessment is commonly used in nursing education (Fordham 2005, Cassidy 2009, O´Connor et al. 2009, Eriksson et al. 2015). There are different interpretations of competence (Klein & Fowles 2009, Kajander-Unkuri et al. 2013), but generally in the literature, competence has been defined as ‘having the necessary ability or knowledge to do something successfully’

(Oxford English Dictionary 2006). In professional education, students’ competence consists of several types of knowledge: theoretical, practical, experiential, regulative and socio-cultural.

Therefore, they need to integrate these forms of knowledge into their own well-structured knowledge base, which enables them to act as qualified professionals (Tossavainen et al. 1998, Turunen 2002, Quinn & Hughes 2007). Specific competence areas in nursing are yet to be defined in the EU, but the contents of the common competence standards set for nursing in Australia and in the United States are similar to those in the EU (Kajander-Unkuri et al. 2013). The NMC (2008) standards for preregistration nursing education competence contain, for example, nurses ability to plan, deliver and evaluate effective, evidence-based care safely and confidently; provide leadership in promoting and sustaining change and innovation, developing services and using technical advances to meet future needs and expectations. These competences are in line with the report of the Willis Commission (2012), which highlighted the future need for a much stronger community focus: public health, health promotion and illness prevention in nursing education.

In the context of discussions on the development of the future requirements for nursing competence, a recent project in Finland had the aim to clarify the competence requirements set

(24)

5

for registered nurses and updating the requirements is also a basis for creating new contents in the curricula of educational institutes. Eriksson et al.’s (2015) task force defined the Finnish professional competence of a nurse responsible for general care as follows: 1. Client-centeredness;

2. Ethics and professionality in nursing; 3. Leadership and entrepreneurship; 4. Clinical nursing;

5. Evidence-based practice and decision making; 6. Education and teaching competence; 7.

Promotion of health and functional ability; 8. Social and health care environment bottom of form;

9. Quality and safety of social and health care services.

Gardner et al. (2007) and Nielsen et al. (2013) have argued that there are limitations on the use of competence-based assessment: Nurses may have knowledge accumulated through education and experience, but they may nevertheless not be ready to use this knowledge in their clinical practice actions. This also confirms why some nursing students may have completely different grades for their theoretical knowledge and clinical performance (Hatfield & Lovegrove 2012, Paskausky & Simonelli 2014). The capability of nursing students describes their ability to use their competence in new as well as familiar circumstances (Brewer & Stewart-Wynne 2013, McGonagle et al. 2015). Rochester et al. (2005) found that while capability in a technical skill is necessary for successful practice as a nurse, capabilities of social and personal ‘emotional intelligence’ are also significant. Successful clinical practice of nursing students is underpinned by their ability to integrate and consistently apply a number of capabilities beyond profession-specific skills and knowledge.

For example, according to Brunou (2009), Epstein & Carlin (2012) and Skela-Savič & Kiger (2015), the nursing students’ ability to detect and solve ethical problems might improve during their clinical practice period, but it is related to the high quality of feedback. Traditionally, educational settings focus on three types of feedback: ‘outcome feedback’ which means knowledge of results, ‘corrective feedback’ which includes provision of the correct answer and

‘process feedback’ which gives to student the explicit information for adapting study strategies.

Formative assessment is often associated with ‘process feedback’. (Giles et al. 2013.) Bloom’s taxonomy (Bloom et al. 1956) is a classification system used to define different levels of the human cognition—i.e., thinking, learning, and understanding. Bloom’s cognitive model is commonly used in nursing education to understand and give feedback the fundamental ways in which nursing students acquire and develop new knowledge, skills, and understanding. It includes six different classification levels: knowledge, comprehension, application, analysis, synthesis, and evaluation. (Zafrir & Nissim 2011.)

Self-assessment is a process where nursing students reflect on their insights, strengths and weaknesses in relation to their nursing competences (Quinn & Hughes 2007, Wade & Hayes 2010, Heron 2011). Fostering the skills of critical reflection occurs during processes, and students need proper formative assessment and support to self-assessment to achieve this level of reflection (Mezirow 1990). According to Taras (2009), self-assessment is a summative process; in order to make the learners’ self-feedback formative, it must also be put to actual use. Nevertheless, the implementation of the feedback must not ignore mental processing, which is where real learning

(25)

and assessment occur. Affective learning outcomes in self-assessment process reflect emotional knowledge, for example satisfaction with the learning experience (Sitzmann et al. 2010).

Summary of concepts and theories of final assessment in clinical learning are presented in Figure 1.

Figure 1. Summary of concepts and theories of final assessment in clinical learning

2.2 CONCEPT OF ASSESSMENT

University-educated teachers usually have the responsibility for guiding, supporting, stimulating, facilitating and evaluating students’ learning (Wade & Hayes 2010, Zafir & Nissim 2011, AACN 2012). In Finland, the nursing teachers’ role is unambiguously to ensure that a certain level is reached and give a grade to the student. Meanwhile in the US, nursing education lacks standardization of nursing teachers’ role in clinical settings due to a lack of a national curriculum

SUMMATIVE ASSESSMENT

=

FINAL ASSESSMENT (In the end of the education modules)

FORMATIVE ASSESSMENT (Ongoing process)

FEEDBACK CAPABILITY COMPETENCE SELF ASSESSMENT

Cognitive Constructivism Socio-

constructivism

SITUATED LEARNING

Behaviorism

(26)

7

for any type of nursing education (Morris & Hancock 2015), whereas in the UK, mentors undertake a certain preparation program in order to be qualified to supervise and assess students in studies leading to registration as nurses (NMC 2008, Lovegrove & Hatfield 2012). These different circumstances affect the role of teachers in different countries. Organizations have arranged this in several ways. Terms such as ‘clinical teacher’, ‘link teacher’, ‘clinical lecturer’, and ‘link tutor’ might be used to describe an experienced registered nurse specialized in a particular domain, who is employed to support nursing students during their clinical practice period (Kelly 2007, Bourgeois et al. 2011). The term ‘teacher’ is used in this study to describe a teacher who is employed by an educational institute and whose role includes ensuring that information and support are given to mentors and nursing students during clinical practice periods; these teachers do not engage directly in patient care (Saarikoski et al. 2007, Collington et al. 2012).

In this study, the term nursing student is used to also describe public health nursing students, midwifery students and emergency care students, who are also registered as nurses similarly as the registered nurses after graduating in Finland. At the EU level, directives regulate that registered nurse education should take at least three years and contain at least 4,600 hours (180 ECTS) of education (EU 2013). Finnish registered nursing education contains 30 ECTS more, amounting to 210 ECTS. The Finnish education for public health nurses and emergency care nurses contains 240 ECTS and for midwives 270 ECTS, and, as mentioned above, these degrees also include nursing education.

There is still confusion about whether the term mentor or preceptor is to be used in the context of assessing students. Typically in United States, the concept of ‘mentoring’ is mostly used in the context of providing mentoring to registered nurses, while ‘preceptors’ are tasked with guiding nursing students. In this study, the term ‘mentor’ is used to represent a clinical nurse who supervises, teaches and assesses nursing students during their clinical practice. The term ‘mentor’

is also used in the United Kingdom for the same purpose. (Jokelainen et al. 2011a.)

2.3 COLLABORATION BETWEEN TEACHER, STUDENT AND MENTOR BEFORE FINAL ASSESSMENT OF NURSING STUDENTS

Several studies (e.g. Walsh et al. 2010, Jokelainen et al. 2013a, Broadbent et al. 2014, Taylor et al.

2015) highlighted the importance of nursing teacher, student and mentor meetings at the beginning of the clinical practice period: it is important that mentors and nursing students receive an orientation for the assessment process and the evaluation form from the teachers so that they will know what must be assessed. Saarikoski et al. (2013) studied nursing students’ perceptions of contacts with nursing teachers during their clinical practice period in nine Western European countries. It was found that in most cases, nursing teachers met their students one to three times

(27)

during their clinical practice period and some also kept in touch with the students by e-mail or telephone.

2.3.1 Assessment forms and mentor education

It is important to document clinical practice requirements, and the task of the assessment is to ensure that a certain level is reached. Several studies (e.g. Butler et al. 2011, Fahy et al. 2011, Nielsen et al. 2013) have found that terminology on assessment forms is sometimes overtly difficult to grasp, and it is rather common that mentors do not understand what the forms mean.

Therefore, the role of the nursing teacher is also highlighted at the beginning of this process.

Carefully prepared assessment forms will make the assessment more objective and help set clear criteria based on learning objectives (Cushing et al. 2011, Ulfvarson & Oxelmark 2012, Sweet et al. 2013,Ossenberg et al. 2016).

Mentor education has an important role in the assessment process because it increases interest in mentoring nursing students (Clemow 2007, Huybrecht et al. 2011, Mårtensson & Löfmark 2013, O’Brien et al. 2014) and increases the mentor’s ability for specific feedback strategies (Yonge et al.

2012). Hallin & Danielson’s (2010) study found that if the mentors have a more positive attitude towards providing mentoring and guidance, they are more likely to give higher grades to the skills of the nursing student. Typically, two- or three-day training sessions are organized for mentors by educational institutes. These days contain information about the curriculum, evaluation criteria and assessment forms. In Luojus’s (2011) study, it was found that mentors who had not attended mentoring education considered nursing students’ learning targets to be clearer than did educated mentors. This means that, in the UK, mandatory standards have been determined for a ‘sign-off mentor’, a nurse mentor who has met additional NMC requirements in order to be able to make judgements about whether a student has achieved the overall standards of competence required for entry to the register at the end of an NMC approved program. These standards state, for example, that mentors have developed their own knowledge, skills and competence beyond registration. They should have been registered for at least one year, and have competence in the field of nursing in which the student is being assessed. (NMC 2008.)

2.3.2 Culture of the clinical placements

Student placements are arranged in a wide variety of treatment environments and they may sometimes find it difficult to demonstrate appropriate expertise in all competence areas (Walker et al. 2011, Stayt & Merriman 2013, Bisholt et al. 2014). Evidence-based nursing education has an important role in nursing education to improve nursing students’ evidence-based practice skills (Florin et al. 2011, Leach et al. 2015). Although registered nurses also highlight the importance of evidence-based practice to be part of their daily practice (Krause-Parello et al. 2013, Christiansen et al. 2014, Veeramah 2016), nursing students sometimes experience a dichotomy between evidence-based teaching in schools and what mentors say is relevant to the ‘real world’

(Seldomridge & Walsh 2006, Brennan & Timmins 2012, Crookes et al. 2013, Killiam & Heerschap

(28)

9

2013). In the study of Saunders (2016) was found that although nurses believed in the value of evidence-based nursing in improving care quality and patient outcomes, they lacked the competencies required for integrating best evidence into clinical care delivery, and therefore did not use it in clinical practice. This might explain the dichotomy nursing students have face in the clinical situations.

Nursing students may have a conception of their ‘ideal’ clinical practice environment, but the

‘actual’ site of their placement might differ from it (Brown et al. 2011, Brennan & Timmins 2012).

For example, Sundler et al. (2014) and Hegenbarth et al. (2015) found that the culture of the clinical unit has an important influence on nursing students’ experiences of learning in clinical situations:

willingness to invest in what nursing students and the unit consider to be an ideal learning environment are highlighted. At the same time, the findings by Curtis et al. (2012) and Smith &

Rogers (2014) showed how nursing students highly valued the possibilities they also got to improve their team work skills for their future role as registered nurses during clinical practice period. When mentors have the possibility to create a supportive relationship with the nursing student, they give more responsibility and independence to the student (Sandvik et al. 2014).

Therefore, mentoring is an important factor to contribute to the achievements of learning outcomes (Luhanga et al. 2010, Löfmark et al. 2012, Stacey & Pollock 2015).

For example, Ness et al. (2010) and Rankin et al. (2010) suggested that nursing students could use action planning to achieve their learning needs and get possibilities to receive feedback. It is possible to arrange these specific nursing contexts, for example, particular patient care situation times and places for assessing students’ behavior (Bott et al. 2011, Yonge et al. 2013). The student’s competencies may also be evaluated much more frequently in a broad range of nursing situations across the clinical practice period (Fahy et al. 2011, Duffy 2013, Hendricks et al. 2013). These difficult situations may increase the nursing student's own responsibility to seek situations where they can demonstrate their expertise (Raines 2012, Brewer & Stewart-Wynne 2013, Killiam &

Heerschap 2013). Several findings (e.g. Henderson & Eaton 2013, Marks-Maran et al. 2013, Muir et al. 2013, Rush et al. 2013, Panzaveccia & Pearce 2014) have indicated that newly graduated nurses also need support from their colleagues and, therefore, it is imperative that nursing students develop their ability to work in different kinds of workplace environments.

2.3.3 Arrangements of mentoring

If working time reserved for mentors with the students during clinical practice period is not sufficient, the accuracy of the evaluation might be affected (Fahy et al. 2011, Huybrecht et al. 2011, Broadbent et al. 2014). The mentor can also have too many students, or frequent changes in staffing might make it extremely challenging to time the mentoring and assessment (Chuan &

Barnett 2012, Hjälmhult et al. 2013, Walker et al. 2013, Germano et al. 2014). However, if mentors feel that they do not even have enough time to perform high quality patient care at the workplace (Blackman et al. 2014, Cao et al. 2015, Fealy et al. 2015), how could they have enough time for mentoring? Registered nurses highlight the significance of organizational effects such as

(29)

relationships with colleagues and management on improving their ability to cope with working situations (Henderson et al. 2010, Congdon et al. 2013, Björn et al. 2015). Additionally, Numminen et al.’s (2015) findings indicated that newly graduated nurses’ willingness to stay in the profession was associated with supportive work environments. This also affects nursing students’ ability to have a long-term relationship with their mentors.

Findings of several studies, e.g. McCarthy & Murphy (2010), Mårtensson et al. (2013) and Sundler et al. (2014), highlighted the importance of mentors’ ability to plan and prepare the clinical education period and, therefore, support from unit managers and colleagues in relation to the timing of mentors’ work is imperative (Orton 1981). In the study by Borch et al. (2013), it was demonstrated that ‘group mentoring’ could be valuable for providing support to mentors during nursing students’ clinical practice periods. Similarly, nursing students who had the same mentor all the time during their clinical practice period were more satisfied than those whose mentors kept changing, sometimes as often as every day (Sundler et al. 2014). Nevertheless, it is also important to gather experience in working with other professionals in clinical environments during the clinical practice period in order to gain competence as a multiprofessional registered nurse who can cooperate with others (Holland et al. 2010).

2.3.4 Nursing students’ needs for feedback

Nursing students often experience stress during their clinical practice periods (Arieli 2013, Cuellar & Zaiontz 2013, Killiam & Heerschap 2013), and therefore appreciate being able to have nursing teachers’ support during their clinical practice periods (Hutchings et al. 2005, Courtney- Pratt et al. 2011, Price et al. 2011, Laws & Brenton 2012, Newton et al. 2012, Morley 2013). In Henderson et al.´s (2012) study, nursing students evaluated that their individual needs and views were not sufficiently taken into account during their clinical placement. Additionally, it is important to understand that nursing students have different learning needs and preferences because of their different learning styles (Lewallen & DeBrew 2012, Roxburgh et al. 2012). In the study by Jokelainen et al. (2013b), student mentors highlighted the possibility to know a nursing student as a person and a learner in order to recognize their individual needs for support. When nursing students understand their levels of thinking and actions, their self-confidence increases and their courage to face further challenges in nursing situations will become stronger (Axtell et al. 2010, Jack 2012, Chan 2013, Sandvik et al. 2014).

The findings by Omer et al. (2015) highlighted how mentors experience their role: evaluating, educating and facilitating nursing students’ clinical practice, protecting patients from healthcare errors and also safeguarding students from making errors that could threaten them or others. The mentor is meant to be a protector providing relevant evaluation feedback to ensure that nursing students have the ability to develop professionally (Ali & Panther 2008, Karayart et al. 2008, Carlson et al. 2009). Results by Anderson (2011) and Flood & Commendador (2016) also suggest that proper mentoring encourages nursing students to achieve necessary knowledge and allows

(30)

11

considering individual needs at learning stages as well as makes nursing students part of the working teams in the practice environments.

The mentors often feel that they do not sufficiently understand the methods used to counsel students and assess their professional growth (McCarthy & Murphy 2008, O’Driscoll et al. 2010, Levett-Jones et al. 2011). In addition, nursing students have a possibility to improve their skills also by taking into account feedback received from patients (Davies & Lunn 2009, Stickley et al.

2011, Yonge 2013). However, O´Brien et al. (2014) suggested that if mentors have the opportunity to receive support from a clinical teacher, they are more satisfied with their mentoring roles.

Mentors need more support from teachers for maintaining mentorships and feel that teachers should pay more frequent visits to clinical sites during students’ placements in them (Huybrecht et al. 2011, Broadbent et al. 2014). Indeed, mentors find it easier to contact nursing teachers in difficult situations related to nursing students if they are already familiar with the nursing teachers at the beginning of the clinical practice period (Duffy et al. 2000, Luhanga et al. 2008, Huybrecht et al. 2011, Earle-Foley et al. 2012).

2.4 ARRANGEMENTS DURING AND AFTER THE ACTUAL FINAL ASSESSMENT DISCUSSION SITUATION

According to Levett-Jones et al. (2011) the teacher, student and mentor should ideally all be present in the final assessment situation. The actual situation of final assessment discussion is meant to be a reciprocal discussion, during which the student, the mentor and the faculty member discuss the achieved competencies of the student. The role of the teacher is to support the mentor and the student in appropriate assessment regarding whether the student has achieved the criteria (Price et al. 2011, Athlin et al. 2012, Courtney-Pratt et al. 2014). However, the nursing students describe their final assessment situation as a very stressful event (Levett-Jones et al.

2011).

2.4.1 Nursing students self-assessment

At the final assessment situation, students normally self-assess their performance (Cotter et al.

2009, Fahy et al. 2011). Nursing students’ awareness of what they know and do not know and the ability to identify what they need to know is key for lifelong learning and becoming a better nurse (Yeo et al. 2010, Casey et al. 2011, Jamshidi 2012, Usher et al. 2015, Wilson et al. 2015).

According to the findings of Yeo et al. (2010) and Löfmark & Thorell-Ekstrand (2014), nursing students are usually prepared before final assessment situations in order to give their self- assessment properly. Dearnley & Meddigs (2007) found that, in some cases, students do not have the required skills for self-assessment and need support in learning the rules of assessment practices. Assessment must also take the views of students into account. However, according to Cole (2009) and Baxter & Norman (2011), nursing students may overestimate their knowledge and skills when they are self-assessing their performance. Findings by Lauder et al. (2008) also

(31)

question the connection between self-assessment and competence. However, e.g. Blackman et al.

(2007) and Moked & Drach-Zahavy (2016) noted that students who had assessed themselves as needing minimal clinical supervision performed significantly better in their final assignments.

2.4.2 Mentors’ assessment methods supported by nursing teachers

Mentors use mostly three or four different assessment methods: observation, asking questions, written exercises, documentation, feedback from staff, feedback from patients (Hyatt et al. 2008, Cotter et al. 2009, Oermann et al. 2009). Knowledge and attitudes of nursing students are usually assessed by mentors more often than skills (Butler et al. 2011). Mentors want clinical practice to be a positive experience for nursing students, which might lead mentors to give higher grades to the students than what they actually deserve. (Heaslip & Scammell 2012, Wells & McLoughlin 2014, Docherty & Dieckmann 2015). Mentors tend to avoid commenting on the more difficult areas of nursing students’ clinical practice actions and, instead, focus their feedback on the students’ strong points (Seldomridge & Walsh 2006, Miller 2010, Struksnes et al. 2012). Mentors often do not have enough courage to fail students who have not demonstrated sufficient competence (Duffy 2003, Brown et. al 2012, Heaslip & Scammell 2012). Some mentors even emphasize that it is not their role to fail students, merely to give feedback (Huybrecht et al. 2011, Yonge et al. 2011).

The role of the nursing teacher has sometimes been debated, and some have even questioned whether the involvement of a clinical nurse teacher is necessary in nursing students’ clinical practice situations. Meanwhile, findings of Löfmark et al. (2012) show that students value supervision provided by teachers even more highly than that by mentors. There might be inconsistencies between mentors’ feedback given to students and feedback that has been previously reported to the teacher in confidence: the mentor might tell the teacher that the student is not competent but give a passing grade in the actual situation of final assessment discussion (Fitzgerald et al. 2010). It is vital to document the clinical practice requirements and the purpose of the assessment to certify that the specific achievement level is met. In some cases, mentors refuse to sign the assessment form because of the short time spent together with the nursing student (O’Connor et al. 2009).

2.4.3 Nursing students’ deficiencies of learning outcomes

For example, Fitzgerald et al. (2010), Brown et al. 2012 and Hunt et al. (2012) found that it is very rare that students fail their clinical practice. If the student does not achieve the clinical competencies, they are usually allowed to have extra time in clinical areas until they are assessed as competent. The studies of nursing students can be terminated for academic failure, but much less commonly because of clinical incompetence (Calman et al. 2002, Larocque & Luhanga 2013).

Mentors may feel that they have failed in their role if the nursing student fails (Duffy 2003, Webb & Shakespeare, 2008). Mentors need support from teachers leading up to the assessment process, especially in assessing the nursing student’s practical skills and in preparing written documentation (Deegan et al. 2012, Cassidy et al. 2012, Broadbent et al. 2014).

(32)

13

Before graduating, nursing students are often worried about the responsibility they are going to have to carry as registered nurses, and worry whether they have enough skills to work with patients (Cooper et al. 2005). This concern is justified, as graduate nurses’ skills have been reported to be somewhat lacking (e.g. Berkow et al. 2009, Attin et al. 2015, Cicolini et al. 2015, Roche et al. 2015, Seeley et al. 2015).

(33)

2.5 SUMMARY

Final assessment is an important face of socio-constructive learning process for ensuring that the nursing student has achieved the educational goals in the clinical practice learning

situations. Theoretical knowledge of the conceptual and contextual perspectives of ‘Final assessment of clinical practice of student nurses’ is presented as the background. Figure 2 illustrates the background of the present study.

Figure 2. Summary of the knowledge basis of the final assessment in clinical practice.

Final assessment of nursing students in clinical practice

Collaboration before final assessment

-Teachers provide orientation on the assessment process and the assessment form -Mentors enable students to demonstrate their expertise in appropriate situations -Students seek to practice and demonstrate their skills -Students receive feedback during the clinical practice period and are able to improve their performance

Arrangements in the actual final assessment placement -Teachers ensure

appropriate assessment discussion and assessment criteria

-Students’ self-assessment -Mentors are requested to give fair and consistent assessment

-Grade the students’

performance

Deficiencies in learning outcomes

-Develop relevant

documentation of learning needs

-If the student does not achieve the clinical competencies

→ extra me in clinical areas until they are assessed as competent

(34)

15

3 Purpose of the study, research questions and design

The purpose of this study was to describe the views of nursing teachers, nursing students, and mentors on the final assessment of nursing students in clinical practice. The study also compared similarities and differences of perception with the concept of ‘final assessment’, aiming to explain the characteristics of the phenomenon of the assessment of nursing students’ clinical practice.

The specific research questions in this study were:

· Based on previous research, what does final assessment of the clinical practice of nursing students entail before final assessment, in the actual final assessment situation and after it? (Original publication I)

· What differences are there in the evaluations of nursing teachers, nursing students and mentors before final assessment, in the actual final assessment situation and after it?

(Original publications II and IV)

· How mentors’ evaluations of final assessment are related to background variables?

(Original publication III)

(35)

4 Implementation of the study

4.1 PROGRESS OF THE STUDY

The study design for this study consisted of a summative literature review and a cross-sectional survey. The progress of the study is presented below in Figure 3.

PHASE I Literature review (2000-2014):

Qualitative study

• Purpose: To provide an overview of the currently used approaches to final assessment of nursing students' clinical practice

• Sample: Articles of previous studies (n=23)

• Method: Narrative literature review

• Data analysis: Inductive content analysis

PHASE II National survey (2012):

Quantitative study

• Purpose: To describe the views of nursing teachers, nursing students, and mentors on the final assessment of nursing students in clinical practice

• Study design: Cross-sectional survey design

• Sample: Nursing teachers (n=108) and nursing students (n=276) in universities of applied sciences, and mentors (n=225) in partner hospitals)

• Method: The questionnaire formed for this study

• Data analysis: Statistical analysis: descriptive statistics, cross-tabulations and exploratory factor analysis

SUMMARY (2016)

• Suggestions for further research and development of final assessment of clinical practice of nursing students

Figure 3. Progress of the study.

(36)

17

5 Data and methods

5.1 PHASE I: REVIEW OF THE LITERATURE 5.1.1 Qualitative data

The literature review was carried out in the first phase of the study to provide an overview of the approaches currently used based on the theoretical contents of the final assessment of the clinical practice of nursing students. The ‘narrative review’ method was used to accumulate and sum up the available evidence on the topic. In order to eliminate any risks of subjectivity, bias and lack of consistency, the review was based on a plan that allows replication if necessary. Therefore, the decisions made at different stages were described and reported carefully. (Aveyard 2011, Webb

& Roe 2007.) In order to enhance the validity of output selection, two research group members independently reviewed and assessed the articles on the basis of the set inclusion and exclusion criteria. Specific levels of value or points of research articles were not used. Inclusion criteria were concerned with: publication time (from January 2000 to May 2014), language (English, Finnish and Swedish), fields of science (nursing, medical, social and education), contents (exclusively concerned with the assessment of student nurses’ clinical practice or the final assessment or evaluation of nursing students’ clinical practice or clinical training), perspective (nursing teachers, nursing students and mentors), publication (peer-reviewed scientific journals) and availability (reasonable resources). Literature reviews and qualitative and quantitative studies were accepted for the analyses together based on the narrative method to attain the widest possible understanding of the aim. The publication time was limited to the period covering the years 2000–2014 because the arrangements concerned with the clinical practice of nursing students have mainly been a focus of interest among researchers from the year 2000 on and there was no need for narrowing the years included in this study. In turn, letters, editorials, non-peer- reviewed articles and articles concerned with patient assessment and simulation sessions, were omitted. For language reasons, four (e.g. Spanish, Italian and Chinese) articles were rejected.

Relevant literature was determined with an accurate, critical and systematic approach via a number of sources. An information specialist assisted the researchers in this process. The following search terms were utilized: nurs* student*, clinical training, practical training, clinical placement, preceptor*, competence*, skill*, performance appraisal, assess*, evaluat*, judgement*.

Relevant articles were acquired in the following electronic databases: CINAHL (EBSCO), PubMed MEDLINE (Ovid), Medic, ISI Web of Science, Cochrane library and Eric (Pro Quest).

Initially, 725 papers were identified in the literature review. At first, after the rejection of publications based on title and duplications, there were in total 331 abstracts for screening. At the abstract stage, 294 publications were rejected. 37 full papers were screened and, after full reading, 14 publications were rejected. In total, 23 full papers were deemed relevant and were accepted to

(37)

the review, as they were explicitly and solely concerned with nursing students’ clinical practice assessment. (Figure 4).

Figure 4. Selection of studies.

5.1.2 Qualitative data analysis

Inductive content analysis (Finfgeld-Connett 2014) was used as the analysis method, involving carefully reading through the material in order to get acquainted with the data and, subsequently, the unit of analysis was chosen. The unit of analysis was a combination of words, or the meaning of a sentence or phrase. Reduced impressions with the same meaning were categorized with the means of classification and then by combining these classes with similar content into subcategories. Consequently, the subcategories with similar contents were combined into upper categories. Finally, data were categorized into three themes. (Paper I.) An example of the content analysis process in one upper category, which is a part of one theme, is presented in Figure 5.

Rejected publications based on title and duplications (n=394)

Total abstracts screened (n=331) Potentially relevant studies identified by

search strategy (n=725)

Rejected at abstract stage (n=294)

Total full papers screened (n=37) Rejected after full reading (n=14)

Total full papers accepted (n=23)

(38)

19

Reduced impressions Class Subcategory Upper category

Figure 5. Example of the content analysis process in one upper category.

Orientation for clinical

practice period Collaboration

between participants

at the beginning

Different treatment environments Familiarization

with assessment

forms

Mentors’

attitudes and qualifications

-Mentors do not always have enough time to spend time with students

-Some schools organize orientation for mentors

-Mentor training increases interest in mentoring

-The more positive the mentor’s attitude towards mentoring and guidance the better they will be at assessing the students’ skills

Acts performed before final assessment of student nurses’

clinical practice

Observation of nursing students’

actions

-Teachers present the evaluation forms -Education institutes have prepared their own grading and assessment forms -A carefully designed evaluation form would make the assessment more objective and clear

-Mentors and students have noted that evaluation forms are sometimes difficult to understand

-Some mentors only evaluate nursing students under certain circumstances -Some mentors evaluate nursing students’

actions all the time

-Nursing students struggle to demonstrate appropriate expertise in different treatment environments

-Teacher, mentor and student meet at the beginning of the clinical practice period -An orientation session on the assessment process is arranged for the mentor and student so that they will be aware of assessment areas

-Students and mentors need the support of teachers in the assessment process

-Students are evaluated by observation, asking questions, self-assessment and writing exercises

-Feedback provided by other staff or patients to students can also be used -There is disagreement whether written assignments guarantee student competence

Assessment by observation by mentors and patients Assessment in different situations Knowledge of assessment forms at the institution

Theoretical competence not enough

Mentor education and attitudes Mentors and students’

knowledge of forms

Assessment in different environments

Time spent by mentors on

mentoring

Nursing student's final assessment in clinical practice : perceptions of teachers, students and mentors

Nursing students’ final assessment in clinical practice.

Perceptions of teachers, students and

mentors

Nursing students’ final assessment in clinical practice.

Perceptions of teachers, students and mentors

Acknowledgements

List of the original publications

Contents

Abbreviations

1 Introduction

2 Final assessment in nursing students’ clinical practice

SITUATED LEARNING

Final assessment of nursing students in clinical practice

3 Purpose of the study, research questions and design

4 Implementation of the study

5 Data and methods