Tensions in learning professional identities – nursing students’ narratives and participation in practical skills during their clinical practice: an ethnographic study

A nurse’s daily clinical work includes performing several different practical skills. In order to provide adequate care, maintain patient safety, and feel comfortable in the profession, registered nurses need to be equipped with requisite skills. Nursing students are required to learn such skills in preparation for their work as nurses [1]. However, there is a lack of knowledge and understanding regarding the ways in which nursing students learn practical skills and how they apply knowledge acquired in the clinical skills laboratory (CSL) in university settings and clinical practice within and across different contexts.

Performing a practical skill is a complex action that requires theoretical knowledge and a critical attitude adapted to each unique patient and specific context, based on current scientific evidence [2, 3]. This can be viewed as a challenge, especially in light of rapid technological developments which require nurses to be up to date with advancements in the field of nursing sciences [4]. Therefore, it is important that the curricula in nursing education promote opportunities for students to develop knowledge and skills in this respect. In other words, frequent opportunities to perform practical skills are needed. Likewise, there exists a need for a reflective academic approach and an understanding that research and evidence are necessary and cannot be separated from the process of learning practical skills [4‐6].

Education for nursing varies from country to country. In Sweden the nursing programme lasts 3 years, leading to a bachelor’s degree. The programme was designed in response to a directive from the European Union that stipulated that at least one-third of the nursing education should consist of theoretical courses, with clinical education comprising a minimum of 50%. Part of the clinical training can be provided in the CSL [7, 8]. The CSL is today seen as an important learning arena that allows nursing students to learn and practise practical skills in a safe way, through simulation at different levels [9]. Previous studies show that students report that training in the CSL helps prepare them for, and gives them self-confidence prior to, practising in clinical settings [1, 10]. It also reduces some students’ concerns about managing practical skills in encounters with patients in real-life situations.

Education in clinical settings is a pivotal part of nursing education. A practicum in different clinical settings provides students with the opportunity to put the knowledge, skills and concepts they have acquired from lectures into practice with real patients, under the guidance of nurses [11, 12]. Furthermore, clinical experience is essential for shaping nursing students’ identity as future nurses. It is widely known that nurses who precept nursing students play a key role in the students’ socialization process; they also have a strong influence on the students’ learning process [13‐16]. Students’ preparation for clinical practice facilitates the socialization process, which in turn facilitates their learning process: thus, a progression of students’ knowledge can be expected to occur [17]. What is taught to the students, what they do or see in clinical settings, and what they experience throughout their university education is what shapes their idea of what a professional nurse is and does [18].

Using a sociocultural framework for socialization and communication as a point of departure means that learning is seen as a social process that is a part of everyday practices. Learning is contextual and includes a dimension of participation in social practices in which cultural tools such as language and material tools and the use of artefacts shape students’ learning [19‐21]. Hence, the practical skills nursing students learn and how they use them are viewed as dependent on the cultural and social contexts that they are part of. The fact that nursing students are provided with opportunities to learn practical skills in two different social settings, the CSL and the clinical setting, suggests that the need exists to facilitate a transfer of knowledge between these settings. Knowledge transfer is a complex process and – for the purposes of the present study – we define it as an application of knowledge from one specific situation to another [22]. A key factor in facilitating this process of knowledge transfer is that the learner can identify similarities across tasks and contexts. Furthermore, nursing education requires guiding students to see similarities and differences in learning situations so that they can understand skills in a wider perspective.

Several studies report that students feel satisfied with their learning in the CSL and feel prepared to perform practical skills; however, this does not automatically mean that the students have adequate knowledge and the capacity to transfer their knowledge from the CSL to clinical settings [23, 24].

The study presented here takes its point of departure in the fact that there is a gap in the research literature regarding the ways in which nursing students deploy CSL-acquired knowledge in clinical settings. Therefore, the aim of this study was to explore how nursing students describe, and use, their prior experiences related to practical skills during their clinical practice.

The overarching theme consists of three sub-themes: “Embodied knowledge”, “Divergent ways of assessing and evaluating knowledge”, and “Balancing approaches”. Each sub-theme, presented under separate sub-headings, is illustrated with the help of quotations, and examples from the data (see Fig. 1, Tables 1 and 2).

An overarching theme regarding tensions in the nursing students’ socialization into clinical practice and their transfer of experiences from the CSL to clinical contexts relates to situated power. The results indicate that the nursing students took different approaches to handling identified mismatch situations, i.e. situations when a practical skill was carried out differently from how it was described in the literature. This reveals different ways in which students navigate tensions related to power differentials. This can be seen in the study’s results, underpinning the sub-themes: “Divergent ways of assessing and evaluating knowledge”, and “Balancing approaches”. Some students did not comment or ask questions even if a situation included practices that the students themselves assessed as being far from evidence-based. Both in informal conversations and in the interviews, some students expressed regret, saying that they should have said something but had chosen to keep quiet, even if it made them feel ashamed of themselves. This result is in line with Lùanaigh et al. [14] and Monrouxe et al. [28] who report that students felt uncomfortable when they witnessed poor practice, both when they intervened or commented and when they remained silent. However, the students in the present study displayed the ability to distinguish between good and poor practices and this is in line with the findings of previous studies [14, 28]. Our interpretation about why some students choose to not speak up relates to the hierarchy in clinical practice. Students recognize their position as newcomers and are afraid of being reprimanded; this is related to situated power. They also want to gain the acceptance of the group, which is easier if they “fit in” and adopt the practices advocated by their preceptor. Furthermore, previous research suggests that students take the side of the group they currently belong to [29], which may explain why students in the present study sometimes defended or excused their preceptors’ incorrect performance. On the other hand, some students spoke up when they identified a mismatch situation, for example by asking their preceptor for the reason behind a certain practice, or commenting that they had learnt it in a different manner at the university. Most students, in their own performance of skills, avoided practices that differed from what they had learnt, even when their preceptor had proposed alternative methods. The analysis suggests that it was both the students’ personal knowledge and degree of self-confidence, and the interaction between the student and the preceptor that shaped the students’ approach. According to Bickhoff et al. [30], it is difficult for students to question poor practice or to decline to do something in a certain way when this is required of them. Going against the grain takes moral courage. Moral courage, according to Lachman [31], involves bridging the gap between personal knowledge and values, and the obligations of a profession. Personal knowledge and experiences can increase students’ self-confidence and this might help them to develop moral courage. One way to increase students’ self-confidence is related to the sub-theme Embodied knowledge. Gaining a “hands-on feeling” allowed students to be more confident in the fluency of their own performance in a patient situation. The need for fluency and confidence can be understood in terms of the students realizing that nurses who are skilled at their work and manage practical skills in a clinical setting can experience their work as rewarding [6]. In line with previous research [32, 33], students in our study expressed that they often felt stressed and worried that their performance might cause injury to their patients. Thus, becoming fluent in their performance has the potential to strengthen students’ self-confidence. Furthermore, students can more easily use their knowledge and adopt new knowledge and skills when they feel confident.

The students used different strategies to get a “hands-on feeling”. Several said that they first wanted to see if the preceptor had some “tricks” they could use and that they had the preceptor explain these. Above all, they wanted the ability to perform different procedures repeatedly on their own, with the preceptor acting as a guide and supervisor. This is in line with previous descriptions in the literature about how important practice time in clinical settings is, and also how important the preceptor’s approach is [15, 16]. Reflecting on actions has previously been described as a prerequisite for developing and learning practical skills [34]. This highlights the importance of both university educators and the preceptor’s role for socializing students in this process.

In this study, there were some students who displayed a lack of proficiency in skill performance. They performed skills improperly and seemed unaware of this. Sometimes potential risks to the patients were evident when task performance was erroneous. Puncture of the veins and inserting a PVC were tasks that the students described as the most challenging, which is in line with Marshburn et al. [35]. Ravik et al. [23] describe some participants who even performed some PVC steps incorrectly in the CSL and transferred these mistakes to the clinical setting. However, what is taught in a lecture in the CSL does not automatically lead to personal learning or the ability to transfer what has been taught [22]. Students have different backgrounds and their learning and development is shaped by their previous experiences, interpersonal communication and interaction with others in a community of practice [19, 20]. Another explanation regarding difficulties related to transfer of knowledge between these different contexts may be related to students’ learning approach in the CSL. Learning in the CSL is based on a mechanical approach with a focus on repetition and familiar elements, an approach that may itself hamper some students’ ability to transfer knowledge to another, much more complex context [23]. To be prepared for performance of practical skills in a real patient situation also requires that students take responsibility on their own to practise their own performance with a reflective approach in the CSL, before they enter clinical settings. Failing this, both their ability to reflect on their own performance of practical skills in clinical settings and their possibility to develop an embodied knowledge, based on the literature, are hampered [1, 32].

Nursing students do not automatically possess the ability to transfer knowledge from one setting to another. Even if they have been taught how to perform a practical skill, their development is shaped by their experiences and interactions with others in a real patient situation. Nursing students’ transfer of acquired knowledge to the clinical context relates to situated power. Students use different ways to navigate the tensions that emerge when practical skills are carried out differently compared with the way they have been taught at the university. Hence, it is important that the preceptors understand how the hierarchy in clinical practice shapes students’ behaviour in clinical settings. Nursing education and preceptors have a mutual responsibility to facilitate students’ increased self-confidence. Reflecting together on actions is a prerequisite for learning and developing practical skills and, thus, professional identities. This highlights the importance of the role of both university educators and preceptors in socializing students in this process.