INR_942

Experience from the Field

1 Approaches to nursing skills training in

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3 three countries inr_942 1..8

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5 K. Williams1 RN, Dip in Nursing, Dip in Adv Educ, Cert ED, MA &
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7 E.A. West2 PhD, ACNS-BC, RN
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9 1 Lecturer in Adult Nursing, Bangor University, Gwynedd, Wales, UK, 2 Assistant Professor of Nursing, Indiana University of
10 Pennsylvania, Indiana, PA, USA 22
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14 WILLIAMS K., WEST E.A. (2011) Approaches to nursing skills training in three countries. International
15 Nursing Review ••, ••–•• 33
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17 Keywords: Canada, Clinical Nursing Skills, Denmark, Education, Nursing, UK, USA 16
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20 There is an ever widening gap existing between education and with mandated clinical skills competencies (Wolford & Hughes 49
21 practice settings for nurses that began with the discipline’s move 2001). Examples of some common clinical skills that nurses must 50
22 away from hospitals as educational settings and into colleges and demonstrate clinical competency performing in the practice area 51
23 universities (Higginson 2004). Challenges have arisen for include proper tube placements, assessment and removal (i.e. 52
24 nursing students regarding the procurement of clinical nursing intravenous therapies, nasogastric and feeding tubes, urinary 53
25 skills during training as a direct result of this move as well as by catheters, etc.), and proper equipment placement, use and dis- 54
26 the ever-burgeoning technological advancements and medical continuation in conjunction with patient assessments (i.e. 55
27 innovations that have continued to grow since that time, particu- oxygen therapy, suctioning, glucose meters, wound-vacs, etc.), as 56
28 larly over the past few decades (Campos de Carvalho 2008; well as basic patient care needs such as infection control, patient 57
29 Robinson 1993). safety, bathing, toileting and proper hygiene. 58
30 The professional requirements of regulatory bodies in the UK 59
31 and USA demonstrate the identified need for some sort of Literature review 60
32 improvement in skills training as well as methods to maintain Although clinical nursing skills training has been identified as 61
33 and update competencies of nurses once they enter the practice vital for safe nursing practice, there is much international debate 62
34 environment. Similarly, in an attempt to address the growing in the literature on what ‘skills’ are essential as well as how they 63
35 dissatisfaction with professional standards in the UK, the United should be taught (Shepherd 2008). Clinical skills encompass a 64
36 Kingdom Central Council for Nursing and Midwifery (UKCC) patient’s physical comfort, hygiene and safe medical treatment. 65
37 commissioned the Nursing and Midwifery Education to Assess In other words, these ‘skills’ have been viewed in a simplistic way 66
38 the Needs of the next Millennium (1999). This re-emphasized or only as a ‘sequence of motor skills’ (Bjork 1999). However, 67
39 the need to ensure ‘fitness of purpose’ of nurses achieving regis- clinical skills embrace dimensions of performance, intention and 68
40 tration. Under the Fitness of Practice Report (UKCC 1999) nursing ‘disciplined’ understanding (Bjork 1999, p. 51). Much of 69
41 learning outcomes gave responsibilities to clinicians to achieve the existing research has been on isolated manual–technological 70
42 clinical nursing skills competency. In the USA, the Joint Com- aspects of skill. When viewed as ‘manual-technical-relational 71
43 mission for Accreditation of Healthcare Organizations (JCAHO) skills’, both learning and transfer of these skills into clinical set- 72
44 requires hospitals to provide evidence of employee compliance tings become more complex (Alteren & Bjork 2006, p. 26). 73
45 At the onset of Project 2000 in the early 1990s in the UK, there 74
46 Correspondence address: Dr Edith A. West, Assistant Professor of Nursing, Indiana was a major shift from clinical tutors taking responsibility for 75
47 University of Pennsylvania, 232 Johnson Hall, 1010 Oakland Avenue, Indiana, PA
1 clinical assessments to mentors being based in the clinical areas. 76
48 15701, USA; Tel: 724-357-3263; Fax: ••; E-mail: edie.west@iup.edu.
Mentors are trained staff with at least 12 months of experience. 77

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2 K. Williams & E. A. West

1 The quality of learning can be influenced by many aspects nursing skills development and competencies assessments in the 50
2 including how busy clinical areas are and the nature of the prac- practice setting, as well as what the discipline was doing to ensure 51
3 tice setting, which can often make it impossible for planned that the public was being cared for by clinically competent nurses. 52
4 learning opportunities to take place as the mentor is pulled in 53
5 many different directions during any one shift. This leaves little Objective 54
6 time to demonstrate skills or talk through events in a meaningful 55
The study was carried out focusing on the following aims: 56
7 way, highlighting the need to find further ways to support and 1 to examine how clinical skills were taught and monitored in 57
8 practise learning in a meaningful and less ad hoc manner. As a Canada, Denmark and the USA. 58
9 result of the need to bridge this gap, methods have been put forth 2 to identify what are seen as key nursing skills in Canada, 59
10 in the literature as a way to focus on students’ attainment of Denmark and the USA. 60
11 competence that include clinicians who are supernumerary to 3 to assess the opportunities to practise key nursing skills in 61
12 the wards (clinical units) demands in order to increase the Canada, Denmark and the USA. 62
13 quality of the students’ practice experience (Andrews & Chilton
63
414 4 2000; Neary 2000). Another similar role to support students is
15 identified as the ‘Lecturer Practitioner’ by Neary (2000). Further, Methodology 64
65
16 in the UK, there has been a reinstatement of clinical labs for Through the financial support of the Florence Nightingale Foun- 66

17 demonstration and practice of skills, which had gone out of dation’s Travel Fund and the generosity of nurse educators in the 67

18 favour in colleges of nurse education as mentors were thought to USA, Canada and Denmark, field observation and unstructured 68

19 be the best choice to show students’ skills in the practice setting interviews of nursing faculty (tutors) and students at select uni- 69

20 as they were arguably more ‘up to date’ than academics. However, versities and affiliate hospitals in Canada, Denmark and the USA 70

21 students have to compete for mentor time and appropriate situ- were carried out. Data were collected via researcher field notes 71

22 ations to practise skills, and there is a wealth of literature arguing and direct observation over a 1-month period in September of 72

23 how competency is more than judging performance but the need 2007. Relevant papers were reviewed from 2006 to 2007. 73

24 for different skills to be applied beyond solely psychomotor 74

25 skills. To ensure that mentors are knowledgeable is also seen as Background of the study 75
26 crucial for students to adequately attain the skills training 76
27 demanded in nursing today (Bewley 1995). Denmark 77
78
28 One method that has provided better safety for patients, less The School of Nursing in the county of Frederiksberg, Hillerod is 79
29 stressful learning for students, and more control over both the one of 21 schools in the country and has been an independent 80
30 quality and quantity of practical skills competency training has school of nursing since 1960. It has been a centre of the Univer- 81
31 been the use of simulation. Clinical simulation provides a simu- sity College of Copenhagen and North Zealand since 2003. 82
32 lated, yet close to life-like environment, featuring original hos- Annually, 128 students are registered for nurse training, which 83
33 pital equipment, ideal to reproduce ‘real’ hospital situations. takes three and a half years to complete over seven semesters. The 84
34 Low- to high-fidelity simulation with mannequins allows inter- clinical placements take place throughout the county in various 85
35 active and, at times, immersive activity by recreating all or part of settings: community hospitals, nursing homes and community 86
36 a clinical experience without exposing patients or students to placements. The school offers undergraduate students a degree- 87
37 associated risks (Maran & Glavin 2003). Much of the literature level education. 88
38 seemed to view simulation as ‘the holy grail’ to all difficulties Field observations were done at clinical placements in various 89
39 associated with the education–practice gap, including everything settings, enabling the researcher to enhance knowledge and gain 90
40 from haphazard and unpredictable skills opportunities pre- perspectives of student nurse skills training. These included 91
41 sented in the practice setting for students, to the increased need several hospitals, a care of the elderly facility, meetings with nurse 92
42 to provide transparency about training and performance stan- educators, staff nurses, students and four different clinical super- 93
43 dards and improve safety to the general public (Kneebone & visors in placement areas. The students observed were studying 94
44 Apsimon 2001). for a Bachelor’s Degree in Nursing over three and a half years. 95
45 Discussions with colleagues and growing discontent from the This is a general course that includes all domains of nursing. The 96
46 public about safety issues beg the question ‘Can we improve the researcher met with the nurse educator who prepared students in 97
47 way student nurses’ clinical skills competencies are assessed in the practice area on site and also met with a selection of upper 98
48 practice?’ This study emerged to investigate what expectations division students to talk to them about their experiences and 99
49 educators in other countries had regarding their students’ clinical courses. 100

© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses
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Clinical skills training in three countries 3

1 In early discussions with college staff in the Danish school of dilemmas in the clinical area. An example of how this would be 50
2 nursing, Denmark, it became evident that they, as in the UK, done would be the supervisor and student looking after a patient 51
3 audited clinical areas to make sure they could provide the right and then leaving the ward to go to the supervisor’s education 52
4 clinical experience to meet the outcomes. These audits included rooms to reflect together on the care given. 53
5 a very detailed profile of the patients nursed in the area. This then The clinical supervisor, while employed by the hospital, 54
6 resulted in clinical goals for the student to achieve with the worked together with the college having agreed to the placement 55
7 ‘clinical counsellor’, who was a nurse educator based on practice outcomes with the placement officer, who kept the profile of who 56
8 instead of at the school. had been where and had the relevant experiences. This in the first 57
9 In any clinical area, the students were very closely supervised semesters, was expected to be very much at the level of feeding, 58
5 10 5 by a ‘clinical counsellor/supervisor’; discussions followed for me toileting and washing patients. The college tutor went to visit the 59
11 to elicit the difference in this role compared with UK mentors. student and clinical supervisor to review progress during the 60
12 They were similar in that they had to be qualified for 12 months placement. The tutors felt that as academics it was not their role 61
13 before they could be considered to be a clinical supervisor and to work with the student clinically. 62
14 they then had to complete a 12- to 14-week course in educational Three times during the academic year, the student had a prac- 63
15 theory. It was stated that it was impossible to take up a position tice assessment that resembled the old total patient care assess- 64
16 to supervise students without this qualification. On discussion, ments carried out in the UK prior to Project 2000. This was 65
17 this seemed to equate in part to our teachers’ training and more where the student took a patient or group of patients and cared 66
18 than the present 10-day course for mentorship in the UK. for them for at least 3 days and then had to do a presentation to 67
19 The key thing about the role of clinical supervisors is that they the clinical supervisor and college nurse educator. This process 68
20 are entirely there for the student. They did not have any other was expected to be at least 2 h or more in length. The tutor felt 69
21 role in the hospital, making them completely supernumerary that they were to make sure that theory that had been covered 70
22 from other clinical demands in the hospital, which they saw as was applied and the clinical supervisor was there for the care 71
23 giving them total freedom to develop students’ needs, albeit prac- issues. This is where students were really to be seen as passed as 72
24 tical or theoretical. It was seen as an important role to hold as proficient in giving care in an integrated assessment, rather than 73
25 they saw themselves as upholding the reputation of the hospital assessing specific skills separately. These were worked on through 74
26 and investing in potential employees. The clinical supervisor was their reflective diary as it was part of their clinical work. These 75
27 paid by the hospital at similar rates to nurse educators at the were used to assess their own professional and personal devel- 76
28 college. This was intriguing as they did not go to the college but opment and were encouraged throughout. Again, emphasis was 77
29 were provided with the required outcomes of the module the on personal development and not about passing or failing. 78
30 student had to achieve, and it was their job to help the student Lessons to be learned from the Danish system were the quality 79
31 meet these goals. of supervision by the clinical counsellors supporting students 80
32 At the college, clinical skills were taught by demonstration. and the freedom in practice that was given to develop each stu- 81
33 These skills very much reflected what we would see as traditional dent’s needs, be they cognitive, psychomotor, etc., in a more 82
34 caring skills, for example, washing, feeding, injection technique, holistic way. Skills were achieved in practice through application 83
35 to name a few. Students were not expected to demonstrate any and the role model of the clinical counsellor. The length of train- 84
36 form of proficiency in college; in practice they were not seen as ing in educational methodologies of clinical counsellors was 85
37 passing or failing competence but developing competence and important to enhance their ability teach students. 86
38 being shown how to improve their clinical nursing skills. Critical 87
39 reflection was encouraged in college and in placement, through Canada 88
89
40 the use of portfolios. The clinical counsellor would go through Sault College is located in Sault Ste. Marie, Ontario and began in 90
41 the portfolio with the students on a weekly basis. Examples were 1965 as the Ontario Vocational Centre. Annually, 60–80 students 91
42 given of how students would be expected to role-model through are registered for nurse training through a partnership with Lau- 92
43 a clinical skill, with colleagues watching them. This was not rentian University in Sudbury, Canada. The school offers under- 93
44 marked but seen as learning from the process, with fellow stu- graduate students degree-level education. The schools’ clinical 94
45 dents giving a breakdown of the events and what was good/bad, placements were in the community and hospital settings, and 95
46 etc. in a reflective way. This was then carried through to the these sites were audited for suitability and student educational 96
47 clinical placements. Personal reports were not written about the need. 97
48 students, but the clinical advisor guided them through achieving Field observations were carried out at the various clinical 98
49 outcomes, which may be, for example, to reflect on the ethical placements similar to those in Denmark and the USA. The Cana- 99

© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses
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4 K. Williams & E. A. West

1 dian and USA educational systems were very similar in that in progressed from custodial patient care at first year to skills such 50
2 any clinical area the students were placed, they were very closely as nasogastric, Foley catheter and intravenous insertions, etc. at 51
3 supervised by a ‘clinical instructor’. The key thing about the role second year, to care of central lines and of clients on ventilators 52
4 of Canadian clinical instructors, much like the USA and Danish by year three. Students also progressed from care of a single client 53
5 ‘clinical counsellor/supervisor’, is that they are entirely there for to care of as many as three or four clients by senior year and 54
6 the student. They did not have any other role in the hospital, students must demonstrate competence in both skills and overall 55
7 making them completely supernumerary from other clinical client assessment and care in order to successfully progress and 56
8 demands in the hospital. The researcher met with students and ultimately graduate. Canada operates a model similar to the USA 57
9 clinical instructors in both college and placement areas. in clinical supervision in practice but does differ in third years by 58
10 At the college, many of the same USA and Danish clinical skills the utilization of registered nurses in hospitals as preceptors for 59
11 were taught by the clinical instructor via demonstration and the student’s final placement. 60
12 student return-demonstration. As in Denmark and the USA, 61
13 students were not expected to demonstrate any form of profi- USA 62
63
14 ciency in college until the end of the rotation, whereby a ‘skills Indiana University is a large American university that was first 64
15 check’ was done, one-on-one with the clinical instructor and chartered in 1871. It has approximately 13 000 students on 65
16 they were not seen as passing or failing competence but devel- campus; taking approximately 115–150 students into its Depart- 66
17 oping competence and being shown how to improve. However, ment of Nursing per intake. Lake Superior State University in 67
18 like the USA schools, if by the end of the rotation, the student Sault Ste. Marie, Michigan is a smaller school with approximately 68
19 was not able to demonstrate proficiency in the skill, they could 2525 students enrolled. This institution was established in 1946. 69
20 fail ‘clinically’. Again, critical reflection was encouraged through Approximately 60 students are registered for nursing. Both 70
21 papers, patient plans of care and student presentations similar to schools had clinical placements throughout their respective 71
22 the Denmark and USA schools, and students were given feedback counties in various settings: hospitals, nursing homes and com- 72
23 on performance after being taught or demonstrated in the lab munity settings. Both schools also offered undergraduate stu- 73
24 setting. Students were evaluated clinically at midterm (formative dents a degree level education and their clinical placements were 74
25 evaluation) and final (summative evaluation) using a clinical audited for suitability and student educational need. Observa- 75
26 evaluation tool that listed all of the relevant course educational tions at both schools included clinical and classroom placements, 76
27 objectives and professional nursing behaviours expected from and also students were being prepared for clinical placement in 77
28 the student. This also mirrored what was being done in the USA. the college lab setting. The researcher followed ‘clinical instruc- 78
629 6 The SIMMs lab in Canada utilized some very complex sce- tors’ in these varied settings. These instructors were either prac- 79
30 narios with students. The model used in Denmark with students’ tising nurses employed by the college or university solely to 80
31 role playing was used here with fellow students observing and mentor/supervise students in the practice area, or nursing faculty 81
32 then reflecting on the actions of the students participating in the (tutors) who taught at the university and also took a group of 82
33 incident. Citing experience, one educator in Canada stated that students into the practice setting as part of their teaching respon- 83
34 they needed to take lead action in the initial use of the simulation sibilities. These ‘clinical instructors’ also had to be experienced in 84
35 as the students did not have the experience in practice of some of the practice area in which they had students and hold a level of 85
36 the things being presented, and it could end in a very negative degree above those they were endeavouring to teach. 86
37 experience if many things went wrong with the patient. It was In both the larger and smaller schools visited in the USA, it 87
38 envisaged that these simulation exercises should build the con- was easier to observe and understand the students’ achievement 88
39 fidence of the student in practice. The education staff at the of clinical nursing skills as these were laid down as clear ‘skill sets’ 89
40 college were very positive about the use of simulation in bridging and viewed as the ‘fundamentals’ that all nurses had to achieve in 90
41 theory and practice, and adding to proficiency and shared their order to progress in the programme. This was done by demon- 91
42 SIMMs lab with Sault Michigan students. The scenarios were stration by the clinical instructor and, in return, demonstrated by 92
43 staff-developed so that they mirrored clinical experience, even the student in a lab setting, and then the student was expected to 93
44 down to physician’s orders and lab results being added in as care practise each skill before coming back for what was known as a 94
45 episodes progressed. It was felt that 20 min in ‘role play’ and the skill ‘check-off’. Practice sessions observed were around an hour 95
46 same amount of time spent reflecting was sufficient for most and a half and the skill (concept, theory, practical application 96
47 situations. and client assessments associated with the task) were taught and 97
48 A lesson to be learned from Canada, and indeed what can be then practised by the student. The student was expected to 98
49 termed the ‘North American model’, is that the student’s skills perform the skill and be observed, achieving a set performance 99

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Clinical skills training in three countries 5

1 against objectives that are primarily psychomotor in nature. The academic essays when doing clinical rotations in either school 50
2 student would not be allowed to go on placement if they were not but had regular testing in class and exams end of term, which 51
3 achieving the required standard and could be removed from built to their final state board of nursing examination. 52
4 training if this was the case. Students seemed to view skill check- In practice, the clinical instructors looked at the quality of 53
5 offs as very stressful events. Mirroring this on placement, the performance and scored students in relation to ability to perform 54
6 researcher witnessed on two occasions students who seemed those items listed as ‘competency criteria’ objectives and their 55
7 unsure about a skill and the nursing faculty made it clear to the relationship to being able to do them independently in practice. 56
8 student that they had better get back to the college the following Lower level students were expected to function with occasional 57
9 week and practise this in the lab. It was then checked by the supporting cues but the need for continuous verbal and physical 58
10 faculty on return to college that the student had booked the skills cues could be considered a ‘failure’ in the upper divisions. Stu- 59
11 lab, utilizing the appropriate faculty there for skills remediation. dents were part of the week at university attending lectures, and 60
12 The nursing faculty at both schools moved the students attending placement with the ‘clinical instructor’. 61
13 through the unit cognizant of which patient the student had The lessons to be learned from the USA system was that the 62
14 nursed previously and deliberately attempting to choose patients tutorial staffs’ continued emphasis to the student was the expec- 63
15 that reflected what the student was learning in the classroom. On tation for students to take self responsibility for learning. The 64
16 placement, they followed students, observing their progress or expectation to practise time and time again to gain and achieve 65
17 working and demonstrating what was needed for the patient. As quality in a skill was seen as important. There was a close rela- 66
18 each patient was in a single room, the staff and student discussed tionship observed in mentoring students through the clinical 67
19 the patient’s needs prior to going in to give patient care. If the placements as the students also had built a rapport with the 68
20 students were on the unit for 10 weeks then the clinical instruc- ‘clinical instructor’. This knowledge of students played an essen- 69
21 tor’s aim was to get them through as many experiences and skills tial part in developing the students’ learning needs. It was also 70
22 as possible while fostering their independence, as the instructor essential that the tutor told the student immediately if they did 71
23 became more confident in the students’ ability. not feel they were achieving the required standard, and laid out 72
24 Instructors could have legally as many as 10 students and yet quite clearly what was to be achieved by next clinical practice 73
25 were constantly engaging with each one. Students were encour- session. This provided a higher degree of supervision than is 74
26 aged to assist one another and to do everything for the patient, common in the UK by qualified teachers. Tutors were not 75
27 even give medications (supervised) once they had achieved the marking or supervising academic essays but supervising the 76
28 relevant skill check-off. This was the baseline for being able to application to practice of students by practising alongside them 77
29 proceed on placement. If the tutor thought a student was not when in the clinical setting. Hospital staff was expected to 78
30 making progress, they used the debrief sessions at the end of shift supplement this role in the lower divisions and select staff may be 79
31 to go through a skill and reflected with each student what they utilized as preceptors (mentors or preceptors) for upper division 80
32 had to achieve. Each student was expected to give a verbal run- students on placement, but these nurses agreed to do so with no 81
33 through of what they had done that shift and reflect on the monetary addition from the hospital. Site visits were then done 82
34 progress. This seemed to foster close relationships between clini- by tutors who place upper division students with staff at the end 83
35 cal instructor and student, especially as they were very encour- of their training, but ultimately the student’s education respon- 84
36 aging and positive in their feedback on student performance. sibility was with the tutor and not the staff. Lessons to be learned 85
37 Every week, the clinical instructor took in a written case profile from this were that students received higher levels of supervision 86
38 from the student, almost a mini case history of the patient looked in North America and Denmark, which seemed to lead to higher 87
39 after. This included profiles, assessments, medical and nursing standards and proficiency in practice. 88
40 care, and medications, which the instructor marked and 89
41 returned to the student on a weekly basis. Workbooks like this Discussion 90
42 were set by every clinical instructor on placement as evidence of Although a convenience sample was used and the study was 91
43 achieving and reflecting on care. At the end of placement, the limited in size and scope, this study highlighted the fact that a 92
44 student had sets of notes that were seen as comprehensive case more holistic approach to student clinical competence, as well as 93
45 histories, incorporating assessment, pathophysiology, role of educational needs, can be more fully met via further exploration 94
46 multidisciplinary team and clinical issues (i.e. research and pro- of the developed role of the ‘clinical counsellor/supervisor’ and 95
47 fessional behaviour). This was then part of the portfolio of devel- ‘clinical instructor’. 96
48 opment reviewed on the student, which looked at clinical Supervision was a role clearly defined by the Danish, Canadian 97
49 development and theory exams. The students did not write long and USA nurses and was seen as crucial in developing practitio- 98

© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses
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6 K. Williams & E. A. West

1 ners by both the clinical teachers and students. The role was able The development of new clinical support models for student and 50
2 to be carried out properly without the demands of patient and mentor through partnerships within the practice setting in UK 51
3 ward care as they were not employed by the educational estab- should be explored further. Also clearer evidence of skill devel- 52
4 lishment but by the clinical area. A similar model had been opment via ‘skills check-offs’ should be made by mentors to 53
5 adopted in North America whereby the nurse educator (tutor) ensure ‘fitness of purpose’ of nurses achieving registration and 54
6 teaching did ‘clinical rotations’ with the students on their module improve student independence and self-responsibility. Discus- 55
7 or worked closely with a practising nurse hired as a ‘clinical sions with educators and practitioners as to the amount of hours 56
8 instructor’. Both worked with their students out on placement, students spend in placement, and the way that time is used 57
9 which appeared to give an ‘ownership’ of the student. This also should also be explored. The development of mentorship courses 58
10 appeared to lead to clinical credibility in preparing nurses of the whereby mentors can be trained to be more analytical in the way 59
11 future, revealing attitudes that the academics felt it was only they they supervise and assess students in specific application of care 60
12 who were in a position to develop student learning. It was seen as in the practice setting, or perhaps a review of the role of the 61
13 unacceptable that the registered nurse could supervise them personal tutor for students, could further develop the concept of 62
14 adequately with the workload given to them by the hospital. creating an academic advisor who is more accessible to students 63
15 Nursing faculty at colleges (lecturers) were as committed to their and more fully engaged in the practice environment with them. 64
16 practice role as much as they were to academic work and admin- Finally, the introduction of clinically based assessments to staff 65
17 istration, which was equally true in North America. This is some- discussions that integrate theory and practice, a look at the devel- 66
18 thing that has been difficult for tutors in the UK to honour. opment of SIMMs labs to enhance realistic learning experiences 67
19 In Denmark and North America students moved from place- and allow students to practice skills in a safe environment prior 68
20 ment to placement during training to gain practice competencies to clinical placement, in addition to allowing staff to have skills 69
21 and overcame a lot of the issues that UK students complain enhanced and/or updated as needed within the practice setting 70
22 about as they were ironed out with the clinical supervisor or are all developments that might usefully be considered in the UK. 71
23 instructor as they occurred, for example, difficulties in perform- 72
24 ing under different mentors, fitting in, being judged on behav- Acknowledgements 73
25 ioural and personality issues, to name just a few. These clinical The financial assistance of a ‘Nightingale Travel Scholarship’ for 74
26 supervisors or instructors also had developed an expertise in Ms Williams to travel to the USA, Canada and Denmark, and the 75
27 supervising students in their clinical areas. The knowledge of the gracious assistance of willing students, faculty and nurses at col- 76
28 student’s ability and performance was clearly far higher than in leges, universities and hospitals in the USA, Canada and 77
29 the UK. Denmark to share how practical nursing skills competencies 78
30 The study also revealed how the UK seems to expect longer were being taught there are gratefully acknowledged. 79
31 exposure of students to clinical work than Denmark, Canada or 80
32 the USA, and the reduced hours spent in clinical practice was
Author contributions 81
33 noticeable. What was witnessed appeared to be much more
This manuscript was created from a ‘Nightingale Scholarship’ 82
34 focused and in-depth learning for students rather than the chal-
Report done by Ms Williams upon completion of field observa- 83
35 lenge often faced by UK students in looking after larger numbers
tions on how practical nursing skills competency training was 84
36 of patients. In the main, students on all areas appeared to only
being done in select schools of nursing abroad (i.e., USA, Canada 85
37 look after one to two patients on shift in the lower divisions. Also,
and Denmark). Dr West edited the report, putting it into manu- 86
38 the clinical supervisors in the countries visited made meaningful
script form, and submitted it for publication. 87
39 experiences for students by focusing on total patient care, and
88
40 not tasks. Any competence the students lacked was picked up and
41 focused on while the student was with their clinical supervisor/ References 89

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44 Conclusion skills-laboratory and the clincal setting: an explorative study. Nordic 93
45 By exploring the developed role of the ‘clinical counsellor/ Journal of Nursing Research and Clinical Studies, 26 (4), 25–30. 88 94
46 supervisor’ and ‘clinical instructor’ abroad, this study highlighted Andrews, M. & Chilton, F. (2000) Student and mentor perceptions of 95
47 that a more holistic approach to practice and student educational mentoring effectiveness. Nurse Education Today, 20, 555–562. 96
48 needs can be more fully met by having the assessor/supervisor Bewley, C. (1995) Clinical teaching in midwifery-an exploration of mean- 97
49 role as a constant presence during students’ clinical development. ings. Nurse Education Today, 15 (2), 129–135. 98

© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses
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Clinical skills training in three countries 7

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8 Kneebone, R. & Apsimon, D. (2001) Surgical skills training: simulation and for Nursing Midwifery and Health Visiting, Sir Leonard Peach, 23
11 9 11 multimedia combined. Medical Education, 35 (9), 909–915. London. 24
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11 tinuum of medical education? Medical Education, 37 (Suppl. 1), 22–28. education clinical audit: WAG. 26
12 12 12 Neary, M., Philips, R. & Davies, B. (1996) The introduction of mentorship Wolford, R. & Hughes, L. (2001) Use of internet to meet competency stan- 27
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