CHAPTER 1

SCAFFOLDING MY STUDENTS FOR CLINICAL PRACTICE:

CLINICAL INSTRUCTORS SUPPORT NURSE INTERNS
INTRODUCTION

Background of the Study

The study addresses a critical concern within the realm of clinical education (Jones and Smith,

2017). A problematic situation wherein nurse interns often encounter difficulties in integrating

classroom learning into real-world clinical scenarios. This disconnect raises concerns about the

overall preparedness and confidence of nurse interns as they navigate the complex demands

of clinical practice. Insufficient support during this crucial period can hinder the development of

clinical skills and decision-making abilities, potentially impacting the quality of patient

care (Johnson, 2019 & White et al., 2020).

Clinical instructor experiences should facilitate and assist students through their transition

period, which begins as senior nursing students in their internship year to become professional

and independent registered nurse (RN). This brings classroom learning to real-life experiences

(Ard et al.2008). Nurses are required to be competent in theoretical and scientific knowledge,

specific psychomotor and technical skills, communication, cultural competence, professional

values, and ethical conduct to face the complexity of real clinical setting (Tilley et al.

2007; Gasberson &Oermann, 2010; Fielden 2012).

 here some study which have been conducted related to your our of interest
According to a review of the literature, few studies have been done on the challenges nursing

students are faced with in the clinical learning environment in Iran; these challenges are still

unknown. Identifying challenges with which nursing students are faced in the clinical learning

environment in all dimensions could improve training and enhance the quality of its planning

and the promotion of the students. We aimed to explain the challenges of the nursing students

in the clinical learning environment. Participants in the study included nursing students and

instructors from Shiraz University of Medical Sciences, Shiraz, Iran (Nahid Jamshidi et al.

2016) Paucity" insufficient, lack,

kakulangan

Most studies focus on the use of scaffolding by faculty or preceptors, but there is a paucity of

research on how clinical instructors, who are often nurses themselves, tailor their approach to

support interns. While some studies have explored the impact of factors like learning styles and

clinical setting, there is a need for more nuanced research on how individual, interpersonal, and

environmental factors interact to influence how scaffolding is delivered and received. Most

studies focus on immediate learning outcomes, but there is a lack of research on how

scaffolding interventions impact interns' transition to practice and their long-term professional

development.

The identified gap underscores the need for a focused investigation into the role of Clinical

Instructors in providing scaffolding support to nurse interns. By exploring the specific challenges

faced by nurse interns under the guidance of Clinical Instructors, the study aims to contribute
valuable insights to address this problematic situation and enhance the overall efficacy of

clinical education in the nursing domain. By studying scaffolding for nurse interns, we can

bridge the gap between theory and practice, enhance competence and confidence, build a

competent nursing workforce, address the nursing shortage, and inform best practices in

clinical education. This ultimately leads to better prepared nurses and improved patient care.
as a nurse interns alam naman din namin
ang perceptions namin about CI, yung
perception nalang ng CI on how they guide
us in practice in theory, skills, competence &
Review of Literature confidence

According to Martini and Mohallem (2021) many nursing students are overwhelmed both

personally and academically. They are easily distracted by a variety of social, emotional,

financial, and time management problems. However, the challenges of the profession require

that students be prepared in critical thinking and clinical judgment skills to face the demands of

practice.

Undergraduate students are (relatively) new to the process of professional decision-making.

They may perceive the situation of the patient as ill-defined, complex, and changing, making it

necessary for clinicians to offer just-in-time and tailored support, which is called

scaffolding. (Spouse 1998) The scaffolding metaphor is used to denote the temporary support

required to accomplish an educational task that the student could not have performed without

the teacher’s guidance ( Volman M, Beishuizen., 2010)

Clinical Instructors supervision during RLE (Related Learning Experiences)

According to Padagas (2020), emphasizes the pivotal role of clinical instructors in shaping

nursing students development, with students expecting a variety of teaching strategies,

assessment techniques, and recognition of their efforts.

In supervising nursing students in the clinical settings during their related learning experience

(RLE), clinical instructors need to be equipped in facilitating quality learning. Several students

focused on this aspect of improvements (McPherson and Candela., 2019). When clinical

instructors are prepared and supported, they can improve their strategies and methods in

handling nursing students in RLE, including their assessments for and f learning. In terms of

assessing, monitoring, and evaluating learning in nursing students, clinical instructors need to

become more equipped with education courses to be ready in teaching. On one hand, a study

found out that education courses can improve teaching ability, reinforce teaching control, and

promote the quality of clinical teaching (Liu et al., 2019). This kind of learning opportunity can

sharpen clinical instructors in the way they operate learning in RLE. This is an excellent

example of continuing education. Continuing education may be delivered with a variety of

programs, activities, and technologies (Shinners & Graebe, 2020) such as education courses

to enhance teaching ability among clinical instructors. George et al. (2020) also pointed out that

nurse educators can use strategies such as use of caring, competent clinical instructors, self-

reflection, peer-support, and debriefing to enhance students' clinical learning experiences.

Nursing faculty members play a pivotal role in the achievement of nursing students' learning

outcomes (Labrague et al., 2019) . Supervised clinical practice influences the students' clinical

learning (Kaphagawani & Useh, 2018). Clinical education is of high importance

(Dinmohammadi et al., 2016).

Clinical Supports for Nurse Interns

According to Jokelainen et al. (2011), supporting students in clinical atmosphere and positive

clinical experience can increase their interest. igorous evaluation of supportive services is

essential to ensure that appropriate services are provided for students at the right

time (Ooms et al., 2013). The results of the study by Msiska et al. showed that students were
left alone when dealing with patients and caring for them and were not supported by nurses

and educators and felt tired, humiliated, discouraged, and unconfident (Msiska et al., 2014). In

their study, Banks et al. showed that students' anxiety and depression in the clinical setting

calls for a great support in such a challenging environment (Banks et al., 2012). nother study

highlighted the role of mentors and department personnel in student support (Williamson et al.,

2011). Based on the study by Gidman et al., the most important areas that students need

support are clinical skills, clinical placement, and self-esteem. Moreover, according to the

results of this study, experienced instructors and students had a more supportive role than

others(Gidman et al., 2011).

Based on the studies mentioned above, support plays a crucial role in clinical education. In

recent decades, there has been much debate on support mechanisms available during nursing

students' internship (Price et al., 2011). Over many years of experience in clinical education of

nursing students in teaching hospitals, authors of this article have also witnessed numerous

problems of students regarding receiving support in various aspects. Furthermore, a review of

the literature indicates that, given the environmental, economic, social, and cultural conditions

associated with the needs of nursing students in the areas of support in clinical education, there

are numerous challenges in Iran and other parts of the world, which are in some cases unique.

Thus, the purpose of this study was to investigate and identify the challenges of supporting the

nursing students in clinical education.

Theoretical Framework

The theoretical underpinning of this study is the “Adaptation Model” developed by

Sr. Callista Roy, a contemporary conceptual model for understanding an individual's manner of

maintaining balance through four major interrelated systems. This model centers on an

individual as a biopsychosocial adaptive system that responds positively to present stimuli. The

model depicts four interrelated systems: physiological- physical mode, self-concept, role

function, and interdependence. The physiological-physical aspect determines how the Clinical

Instructors is affected by the stimuli physically and mentally such as the existence of stress and

depression. The self-concept on the other hand is utilized to explore the Clinical Instructors’

sense of purpose and how the stimuli affect the identity integrity which includes body image

and self-ideals. For the role function and interdependence, it assists in investigating the effect

of the stimuli in the manner of performing the role as a Clinical Instructors and a health care

provider despite the existing stimuli and attaining relational integrity by giving and receiving

love, respect, and value respectively.

By studying scaffolding for nurse interns, we can
bridge the gap between theory and practice, enhance
competence and confidence
This theory served as the foundation for exploring the experiences and adaptive responses of

the Clinical Instructors as these four coping processes are stimulated by the presence of the

stimuli. The focal stimuli in this study are the conflicts that arise critical concern within the realm

of clinical education and the affected nursing principles, especially in clinical settings. The effect

of these stimuli on the coping processes of the Clinical Instructors significantly affects the

experience and perception of the Clinical Instructors which are the primary aspect to be

investigated in this study.

Research Objectives

This study aims to explore the Clinical Instructors support to Nurses Interns.

1. Determine the types of support given by clinical instructors in terms of:

➢ Practice of theory and skills

➢ Clinical Competence

➢ Confidence

Scope and Limitations

This study will focus on clinical instructors support to nurse interns to promote deeper learning

in clinical practice. The dimension of scaffolding nurse interns for clinical practice are to provide

comprehensive support, ensuring that nurse interns develop the competencies and confidence

needed for successful clinical practice. The participants of this study are the clinical instructor

who were assigned at the Kidapawan City, North Cotabato. Interview guide questionnaires will

be utilized in gathering data from the participants of the study.

Definition of Terms

Adaptation Model: Developed by Sr. Callista Roy, a conceptual model focusing on an

individual's adaptive responses to stimuli in the biopsychosocial context.

Biopsychosocial: Pertaining to the integration of biological, psychological, and social aspects.

Challenges: Difficulties and obstacles faced by nursing students, including social, emotional,

financial, and time management issues.

Clinical Competence: The ability of nurse interns to perform clinical tasks effectively.

Clinical Education: The process of preparing nursing students for real-world clinical practice.

Clinical Instructors: Professionals guiding and supporting nurse interns during their clinical

practice.

Clinical Practice: The practical application of theoretical knowledge and skills in a clinical

setting.

Clinical Skills: Proficiencies and abilities required for effective clinical performance.

Competence: The overall capability and effectiveness of individuals, encompassing various

dimensions in nursing.

Confidence: The level of self-assurance nurse interns possess in their clinical practice.

Coping Processes: Strategies individuals use to adapt to stimuli, as outlined in the Adaptation

Model.

Critical Thinking: The ability to analyze and evaluate situations for effective decision-making

in nursing practice.
Disconnect: A problematic situation where nurse interns face difficulties integrating classroom

learning into clinical scenarios.

Identity Integrity: Within the self-concept system, exploring how stimuli affect the Clinical

Instructors' sense of purpose, including body image and self-ideals.

Nuance- having or characterized by subtle and often appealingly complex qualities, aspects,

or distinctions (as in character or tone) a nuanced performance.

Paramount- is one of the world’s leading producers of premium entertainment content that

connects billions of people in nearly every country in the world.

Phenomenon- a fact or situation that is observed to exist or happen, especially one whose

cause or explanation is in question.

Physiological-Physical: The system in the Adaptation Model determining how Clinical

Instructors are affected physically and mentally by stimuli.

Practice of Theory and Skills: The application of theoretical knowledge and practical skills in

the clinical setting.

Preparedness: The state of being ready, addressing concerns about the readiness of nurse

interns for clinical practice.

Quality of Patient Care: The standard of care provided to patients, influenced by the

competence and preparedness of nurses.

Realm- is an area that is ruled by something. If you are a controlling cook who doesn’t like

anyone to do anything else in the kitchen, then the kitchen is your realm.
Scaffolding – is an instructional practice where a teacher gradually removes guidance and

support as students learn and become more competent. Support can be for content, processes,

and learning strategies.

Undergraduate Students: Students who are relatively new to the process of professional

decision-making in nursing.

Vivid- is an adjective that describes a bold and bright color, an intense feeling, or an image in

your mind that is so clear you can almost touch it.

CHAPTER 2

METHODOLOGY

This chapter will include various methodologies that we are going to use to gather and analyze

data which are applicable in our research. The methodologies include the research design,

research locale, participants, research instrument, data gathering and data analysis that can

be employed in our study.

Research Design

The study is a qualitative type of research. It is a type of research that gathers participants’

experiences, perceptions, and behaviors. It answers the hows and whys instead of how many

or how much ( Moser A., Korstjens I., 2017). Qualitative research is chosen for its ability to

explore and understand complex phenomena, attitudes, and experiences in-depth, providing

rich insights into the perspectives of participants (Creswell & Creswell, 2017). The focus on

participants' subjective experiences and perspectives is well-suited to the nature of the

research questions (Merriam, 2009). Qualitative methods offer flexibility, enabling researchers

to adapt to emerging themes and explore unexpected avenues during the study (Merriam,

2009).

Moreover, a qualitative research approach views human thought and behaviour in a social

context and covers a wide range of phenomena in order to understand and appreciate them

thoroughly. Human behaviours, which include interaction, thought, reasoning, composition, and

norms, are studied holistically due to in-depth examination of phenomena. The close

relationship that exists between the researcher and the participants in this approach makes it
 easy for the participant to contribute to shaping the research. This however account for

significant understanding of experiences as its participants understand themselves and also

understand experience as unified (Sherman and Webb, 1990, p5; Lichtman, 2013)

We choose a qualitative type of study to enhance the understanding and supporting nurse

interns in clinical practice. It can provide insights that can inform the development of effective

scaffolding interventions and improve the transition of nurse interns from the classroom to the

bedside.

Research Locale and Participant

The research will be conducted at Kidapawan City and the respondents of the study will be the

Clinical Instructors from different health institutions in Kidapawan City. The participants of the

study will be selected according to the following criteria:

a.) Clinical Instructors who had experience in the field

b.) Willing to participate in the study

Research Instruments

The researchers used interview guide questionnaire as an instrument which is formulated to

gauge the data needed in the study. This approach will consist of open-ended questions based

upon the experiences of Clinical Instructors to support their Nurse Interns during their hospital

exposure. In this research instrument, it aim to employ targeted questions and the open-

ended questions will enhance the clarity on specific points of the data gathering.

Data Gathering Procedure

In this study, the researchers begin with the foundational task of securing permission and

ethical approval. Before initiating any data collection, it is imperative to seek permission from

relevant authorities and obtain informed consent from potential participants. This involves

clearly articulating the study's purpose, the participants' role, and their rights, ensuring that

participation is voluntary. Once permission is granted, the development of an interview guide

questionnaire tailored to the research objectives is essential. This questionnaire serves as a

structured tool to systematically extract pertinent information from participants. Before the

official data collection, a pilot test is conducted to refine and clarify questions. This will be given

to the clinical instructors in Kidapawan, City based on predetermined criteria, and interviews

are scheduled at mutually agreeable times. During the interviews, the predetermined

questionnaire guides the process, allowing for both open-ended and closed-ended inquiries to

gather comprehensive and meaningful data. Throughout this entire process, maintaining

participant privacy, confidentiality, and overall ethical standards remains paramount. After the

data collection, participants are debriefed, and any questions or concerns are addressed. The

collected data are then meticulously analyzed, leading to the interpretation and reporting of

findings that contribute to the broader understanding of the research area.

Data Analysis

The gathered data undergoes analysis using the thematic analysis method. In accordance with

the guidelines outlined by Virginia Braun and Victoria Clarke in their 2006 book, the analysis

follows a structured six-step process:

1. Become Familiar with the Data: The primary focus during this phase is to transcribe the

data into a written form. Intelligent verbatim transcription is employed, eliminating

irrelevant data such as fillers to enhance the identification of participants' significant

responses. A comprehensive understanding of the data is gained through open-minded

reading, preparing for the subsequent phase. Transcribe data into written form, focusing on
significant participant responses. Use intelligent
verbatim transcription, omitting fillers for clarity.

2. Generate initial Codes: Researchers identify and record meanings in participants' notable

experiences and responses, a process known as coding. Differences and similarities among

meanings are noted, giving rise to common concepts and patterns, ultimately forming themes.

3. Search for Themes: Various codes from the previous phase are organized and

interconnected to generate themes.

*Generate Initial Codes: Identify and record Search for Themes

meanings in participants' experiences, known as Organize and interconnect various
coding. Note differences and similarities to create codes to generate overarching
common concepts and patterns, ultimately themes representing key aspects of
forming themes. the data.
4. Review Themes: Researchers scrutinize and evaluate the generated themes. Themes may

be combined, refined, disregarded, or split based on identified concepts and contradictions.

Scrutinize and evaluate generated themes. Combine, refine, discard,

or split themes based on identified concepts and contradictions.

5. Define Themes: Themes and sub-themes are given comprehensive definitions and names

based on the underlying concepts before being prepared for written documentation.
Give comprehensive definitions and names to themes and sub-themes
based on underlying concepts. Prepare them for written documentation.

6. Writing-Up: The final step involves writing the analysis of the collected data based on the

identified themes. The written document typically includes sections such as introduction,

methodology, discussion of findings, and conclusion. Researchers may also create a thematic

map to visualize interconnections between themes.

Write the final data analysis, including sections like introduction,

methodology, discussion of findings, and conclusion.

Trustworthiness of the Study

The trustworthiness or rigor of a study refers to the degree of confidence in the data,

interpretation, and methods used to ensure the quality of the study (Pilot & Beck, 2014). In each

study, researchers should establish the protocols and procedures necessary for a study to be

considered worthy of consideration by readers (Amankwaa, 2016). Although most experts

agree trustworthiness is necessary, debates have been waged in the literature as to what

constitutes trustworthiness (Leung, 2015).Criteria outlined by Lincoln and Guba (1985) are

accepted by many qualitative researchers and will be the focus of this column. These criteria
include credibility, dependability, confirmability, and transferability; they later added authenticity

(Guba & Lincoln, 1994). Each of these criteria and the typically used procedures will be outlined.

Credibility of the study, or confidence in the truth of the study and therefore the findings, is the

most important criterion (Polit & Beck, 2014). This concept is analogous to internal validity in

quantitative research. The question a reader might ask is, "Was the study conducted using

standard procedures typically used in the indicated qualitative approach, or was an adequate

justification provided for variations?" Thus, a grounded theory study should be conducted

similarly to other grounded theory studies. Techniques used to establish credibility include

prolonged engagement with participants, persistent observation if appropriate to the study, peer

debriefing, member-checking, and reflective journaling. Evidence also should be presented of

iterative questioning of the data, returning to examine it several times. Negative case analysis

or alternate explanations should be explored as well.

The nature of transferability—the extent to which findings are useful to people in other

settings—is different from other aspects of research in that readers actually determine how

applicable the findings are to their situations (Polit & Beck, 2014). Although this is considered

analogous to generalization in quantitative research, it is different from statistical generalization.

Qualitative researchers focus on the informants and their stories without saying this is

everyone's story. Researchers support the study's transferability with a rich, detailed description

of the context, location, and people studied and by being transparent about analysis and

trustworthiness. Researchers need to provide a vivid picture that will inform and resonate with

readers (Amankwaa, 2016).

Dependability refers to the stability of the data over time and under the conditions of the study

(Polit & Beck, 2014). It is similar to reliability in quantitative research, but the stability of the

conditions depends on the nature of the study. A study of a phenomenon experienced by a

patient may be very similar from time to time. In a study of a program instituted at a hospital,

however, conditions will change. Procedures for dependability include the maintenance of an

audit trail of process logs and peer debriefings with a colleague. Process logs are researcher

notes of all activities that happen during the study and decisions about aspects of the study,

such as whom to interview and what to observe.

Confirmability is the neutrality or degree to which findings are consistent and could be repeated.

This is analogous to objectivity in quantitative research (Polit & Beck, 2014). Methods include

the maintenance of an audit trail of analysis and methodological memos of log. Qualitative

researchers keep detailed notes of all their decisions and their analysis as it progresses. In

some studies, these notes are reviewed by a colleague; in other studies, they may be discussed

in peer-debriefing sessions with a respected qualitative researcher. These discussions prevent

biases from only one person's perspective on the research. In addition, depending on the study,

the researcher may conduct member-checking with study participants or similar individuals. For

example, Nickasch and colleagues (2016) presented their findings at a national research

conference and received feedback indicating the presented issues were similar for other

nurses.

These criteria collectively contribute to the overall rigor and reliability of the
study.
Ethical Considerations

In this study, upholding the confidentiality, privacy, and overall safety of participants is of

paramount importance. To guarantee confidentiality, participants will be assigned unique

identifiers, and all identifiable data will be securely stored, with restricted access granted solely

to authorized researchers. Privacy will be maintained by carefully selecting private settings for

data collection and utilizing secure face-to-face interactions. Transparent communication

during the informed consent process will highlight the protective measures in place. A thorough

risk assessment will precede the study, addressing potential physical, psychological, or social

risks. Participants will receive guidelines for reporting any discomfort, and regular check-ins will

monitor their well-being. Safety protocols, including briefings and debriefings, will be enacted

for physical interactions, aligning with ethical guidelines and gaining approval from relevant

ethics review boards. Robust data security measures, including encryption and access

controls, will be implemented to safeguard participant information, with continuous updates to

align with current standards. Through these measures, We are dedicatedto ensuring ethically

sound research conduct and prioritizing the well-being and safety of all participants. (Sanjari et

al., 2014)